Combinations of chromium or vanadium with antidiabetics for glucose metabolism disorders

ABSTRACT

Compositions and methods of using the same for the treatment of diabetes and other disorders of glucose metabolism are provided. Compositions may include an anti-diabetic agent and one or more of a bioavailable source of chromium and vanadium.

RELATED APPLICATION INFORMATION

This Application is a Continuation-in-Part of application Ser. No.09/156,102, filed Sep. 17, 1998, and this Application claims the benefitof priority under 35 U.S.C. section 119(e) to Provisional Application60/126,489, filed Mar. 26, 1999, both of which Applications are herebyincorporated by reference in their entirety.

BACKGROUND OF THE INVENTION

Diabetes adversely affects the way the body uses sugars and starcheswhich, during digestion, are converted into glucose. Diabetes mellitusis generally caused in almost all instances by diminished rates ofinsulin secretion (absolute or relative) by the beta cells of the isletsof Langerhans in the pancreas or by reduced insulin sensitivity.Insulin, a hormone produced by the pancreas, makes the glucose availableto the body's cells for energy. In muscle, adipose (fat), and connectivetissues, insulin facilitates the entry of glucose into the cells by anaction on the cell membranes. The ingested glucose is normally convertedin the liver to CO₂ and H₂O (50%); to glycogen (5%); and to fat(30-40%), the latter being stored in fat depots. Fatty acids from theadipose tissues are circulated, returned to the liver for re-synthesisof triacylglycerol and metabolized to ketone bodies for utilization bythe tissues. The fatty acids are also metabolized by other organs.

The net effect of insulin is to promote the storage and use ofcarbohydrates, protein and fat. Insulin deficiency is a common andserious pathologic condition. Diabetes is commonly divided into twotypes: Type 1 diabetes (juvenile-onset, insulin-dependent diabetesmellitus [IDDM]) that usually, but not always, begins in early life, andType 2 diabetes (maturity-onset diabetes, non-insulin dependent diabetesmellitus [NIDDM]) that usually, but not always, begins in later life. InType 1 diabetes, the pancreas produces little or no insulin, and insulinmust be injected daily. In Type 2 diabetes, the pancreas retains theability to produce insulin and in fact may produce higher than normalamounts of insulin, but the amount of insulin is relativelyinsufficient, or less than fully effective, because of cellularresistance to insulin. Type 2 diabetes may present as non-obese NIDDM,obese NIDDM,

or maturity-onset diabetes of the you

(MODY). Type 1 is likely to occur in those with a family history ofdiabetes and is characterized by blurred vision, itching, unusualthirst, drowsiness, obesity, fatigue, skin infections, slow healing, andtingling or numbness in the feet.

Type 1 Diabetes

Type 1 diabetes accounts for around ten percent of all cases of diabetesmellitus. The action of Type 1 diabetes is to cause hyperglycemia(elevated blood glucose concentration) and a tendency towards diabeticketoacidosis (DKA). Currently treatment requires chronic administrationof insulin. No single standard exists for patterns of administration ofinsulin and treatment plans vary and may be selected from one of threetreatment regimens: conventional, multiple subcutaneous injections, orcontinuous subcutaneous insulin infusion. Conventional insulin therapyinvolves the administration of one or two injections a day ofintermediate-activity insulin such as zinc insulin or isophane insulinwith or without the addition of small amounts of regular insulin.Regular insulin has a duration of action lasting from 3 to 8 hours,whereas other forms of insulin are absorbed slowly from the injectionsite and therefore have effects that may last as long as ten toforty-eight hours. The multiple subcutaneous insulin injection techniqueinvolves administration of intermediate- or long-acting insulin in theevening as a single dose together with regular insulin prior to eachmeal. Continuous subcutaneous insulin infusion involves the use of asmall battery-driven pump that delivers insulin subcutaneously into theabdominal wall, usually through a butterfly needle. Insulin is deliveredat a basal rate continuously throughout the day, with increased ratesprogrammed prior to meals. Insulin may also be delivered by way of animplant that is administered parenterally, or by way of slow-releaseformulations.

Type 2 Diabetes

Type 2 diabetes is marked by hyperglycemia that is not linked with DKA.Sporadic or persistent incidence of hyperglycemia may be controlled byadministering insulin. Uncontrolled hyperglycemia may transientlyadversely affect the insulin-producing cells of the pancreas (thebeta-islet cells), which may eventually result in greater insulindeficiencies. In most Type 2 diabetic subjects, the fundamental defectsto which such abnormalities may be traced include (1) a reduced entry ofglucose into various “peripheral” tissues,

(2) an increased liberation of glucose

the circulation from the liver. There is therefore an extracellularglucose excess and an intracellular glucose deficiency. There is also adecrease in the entry of amino acids into muscle and an increase inlipolysis. The cumulative effect of these diabetes-associatedabnormalities may be severe blood vessel and nerve damage. Type 2diabetic subjects may be treated with insulin, if necessary.

Type 2 often develops in subjects of certain at risk populations.Obesity predisposes an individual to Type 2 diabetes due to long-termeffects on insulin resistance. If the beta-cells are compromised,diabetes may well ensue. Type 2 also develops from the at riskpopulation of individuals with gestational diabetes mellitus (GDM).Pregnancy normally is associated with progressive resistance toinsulin-mediated glucose disposal. In fact, insulin sensitivity is lowerduring late pregnancy than in nearly all other physiological conditions.The insulin resistance is thought to be mediated in large part by theeffects of circulating hormones such as placental lactogen,progesterone, and cortisol, all of which are elevated during pregnancy.In the face of the insulin resistance, pancreatic beta-cellresponsiveness to glucose normally increases nearly 3-fold by latepregnancy, a response that serves to minimize the effect of insulinresistance on circulating glucose levels. Thus, pregnancy provides amajor “stress-test” of the capacity for beta-cells to compensate forinsulin resistance.

Other populations thought to be at risk for developing Type 2 diabetesare the elderly; certain minorities; persons with Syndrome X; personswith concomitant hyperinsulinemia; persons with insulin resistancecharacterized by hyperinsulinemia and by failure to respond to exogenousinsulin; and persons with abnormal insulin and/or evidence of glucosedisorders associated with excess circulating glucocorticoids, growthhormone, catecholamines, glucagon, parathyroid hormone, and otherinsulin-resistant conditions.

Treatment of Diabetes and its Complications Diabetes has become aleading health care issue in the United States and other countries,accounting for one seventh of the national health care budget. Theincidence of diagnosed diabetes has increased five-fold in America overthe past 35 years, with currently 8 million diagnosed diabetic patients,another estimated 8 to 12 million undiagnosed diabetic individuals, andstill an additional 23 million Americans with pre-diabetes, or impairedglucose tolerance (IGT). As the American populace continues its trendtowards aging, obesity, and greater minority representation, the numberof individuals who are diabetic and suffer from other glucose metabolismdisorders is likely to increase.

Diabetic Complications and Symptoms

Although progress has been made in reducing the short term complicationsof diabetes, e.g. ketoacidosis, dehydration, and non-ketotichyperosmolar coma, less progress has been made in preventing orminimizing the chronic complications of the disease, e.g. prematureatherosclerosis, retinopathy, nephropathy, and neuropathy. It isestimated that a diabetic patient's life is shortened by 10 to 15 years,and those years of life are distinguished by significantly increasedmedical care costs as compared to a non-diabetic patient. Somecomplications of diabetes includes blindness and end-stage renaldisease.

Another complication of diabetes mellitus is diabetic neuropathy (alsocalled neuritis), which has been an unusually refractive complication ofdiabetes. Endoneural hypoxia is the overt cause of diabetic neuropathy.Early symptoms include numbness, irritation, and pain, usually in theextremities, and more advanced ones include gastroparesis and impotence.The conversion of the essential fatty acid (EFA) linolenic acid togamma-linolenic acid (GLA) appears to be impaired in diabetics becauseof a lack of the enzymes delta-6-desaturase and/or delta 5-desaturase.Consequently, there is shortage of GLA and its metabolites, prostacyclinand prostaglandins, the chronic deficiencies of which contribute to thepathogenesis of diabetic neuropathy. Prostacyclin (PGI2) is avasoprotective molecule with multiple physiological functions, and theenzyme cyclooxygenase (cox) is involved in its synthesis. Two isoformsof cox have been identified to date: cox-1, which produces bothprostacyclin and anti-inflammatory prostaglandins, and cox-2, whichproduces both thromboxane A₂ (TxA₂) and some of the prostaglandinsresponsible for inflammation. Many therapeutics for pain managementinhibit both cox-1 and cox-2, thereby reducing inflammation caused byprostagladins produced by cox-2, but also inhibiting production ofprostacyclin, which may exacerbate a prostacyclin deficiency resultingin neuropathy. In addition, neurotrophic factors, such as thesuperfamiliy of neurotrophins including nerve growth factor, may presentan alternative pathogenic mechanism that results in neuropathy.

Another complication of diabetes is increased cardiovascular riskfactor, especially among women. A man's risk of dying by heart diseasedoubles upon developing diabetes, whereas a woman's risk increases threeto five-fold.

In particular, Type 2 diabetes presents a number of co-existentcardiovascular metabolic risk factors, e.g., insulin resistancehyperinsulinemia, central obesity, hypertriglyceridemia, low HDL level,quantitatively abnormal LDL (diabetic dyslipidemia), hypertension,glucose intolerance, and elevated blood pressure. This state has beenidentified as “Syndrome X.” These cardiovascular risk factors mayprecede the onset of diabetes by as much as a decade, and they mayexplain the presence of overt clinical cardiovascular disease in as manyas 60% of newly diagnosed diabetic patients. For example, elevatedglycated hemoglobin (HbA1c) is believed to be a risk marker forshort-term mortality following acute myocardial infarction innon-diabetic subjects.

Diabetic dyslipidemia is another complication of diabetes and is ofimport to cardiovascular health. Plasma cholesterol and triglyceridesare transported in lipoproteins (HDL, VLDL, and LDL).Dyslipoproteinemias are conditions in which the concentration andcomposition of these cholesterol- or triglyceride-carrying lipoproteinsare abnormal. Elevated concentration of lipoproteins LDL and VLDL mayaccelerate the development of atherosclerosis, with the secondarypossibilities of thrombosis and infarction. Evidence suggests thatreduction of the concentration of lipoproteins LDL and VLDL in plasmamay diminish the increased risk of atherosclerosis that accompanieshyperlipoproteinemia. Dyslipoproteinemias have been designated as eitherprimary or secondary. Secondary dyslipoproteinemias involvecomplications of a more generalized metabolic disturbance, such asdiabetes mellitus or excessive intake of ethanol. In contrast, primarydyslipoproteinemias are typically caused either by an inheritedsingle-gene defect (monogenic dyslipoproteinemias) or a combination ofmultiple subtle genetic factors that act together with environmentalones (multifactorial or polygenic dyslipoproteinemias).

Evidence suggests that treatment of hyperlipoproteinemia may diminish orprevent atherosclerotic complications. For example, populations studieshave shown that an elevated concentration of total cholesterol orLDL-cholesterol in plasma constitutes a major risk factor for theoccurrence of atherosclerotic events. In the case of monogenicdisorders, family studies have documented a markedly increased risk ofvascular disease among affected members. These is evidence thatreduction in plasma concentrations of LDL-cholesterol may reduce therisk of coronary heart disease (CHD).

Furthermore, there may be an excessive risk of cardiac mortality indiabetic patients even after adjusting for the co-existence of othercardiovascular risk factors such as hypertension, dyslipidemia, andcigarette smoking. This increase risk of cardiac mortality is secondaryto both the atherogenicity of insulin resistance, which may precede theonset of diabetes by at least 8 years, and the atherogenicity ofundiagnosed and uncontrolled hyperglycemia, which may be present for9-12 years before diabetes is first diagnosed.

One means of attenuating the cardiovascular effects of diabetes, wouldinvolve earlier diagnosis and improved management of diabetes to reduceinsulin resistance and control blood glucose. To this end, screening forrisk factors for vascular complications followed by appropriatetreatment may be appropriate.

Pharmacologic Interventions

Current drugs or anti-diabetic agents used for managing Type 2 diabetesthat are well-known in the art generally fall within a number ofcategories: the biguanides, thiazolidinediones, the sulfonylureas,benzoic acid derivatives and glucosidase inhibitors. This drugs usuallyhave distinct modes of action. The biguanides, e.g., metformin, arebelieved to prevent excessive hepatic gluconeogenesis. Thethiazolidinediones are believed to act by increasing the rate ofperipheral glucose disposal. The sulfonylureas, e.g., tolbutamide andglyburide, and the benzoic acid derivatives, e.g. repaglinide, lowerplasma glucose by stimulating insulin secretion. The alpha-glucosidaseinhibitors competitively inhibit alpha-glucosidase, which metabolizescarbohydrates, thereby delaying carbohydrate absorption and attenuatingpost-prandial hyperglycemia. In addition, there are a number of proposedtherapies for treatment of diabetes that have not yet been approved forhuman use.

Because of the many complications that accompany diabetes and otherglucose metabolism disorders, there remains a need to improve ontreatment methods presently available, and to devise new means oftreatments for preventing the onset and reducing the severity of Type 1and 2 diabetes. In part, the present invention is directed tocompositions comprised of a component and an anti-diabetic agent, andmethods for using them, and programs thereof, that have been observed toalleviate or prevent diabetes and its associated sequelae. The subjectcompositions, and the methods of the using the same, may be used earlyin the course of developing diabetes and glucose metabolism disorders toreduce such complications.

SUMMARY OF THE INVENTION

The present invention represents new and important treatments ornutritional regimes for maintaining or promoting health, particularlythe treatment of diabetes, pre-diabetes, and the reduction or avoidanceof the onset of diabetes.

In certain embodiments, the present invention provides compositions, andmethods of using the same, for regulating, modulating or alteringglucose metabolism in a manner beneficial to the patient. Generally,various embodiments of the invention may be applied or tailored tospecifically treat or address each condition described herein and otherslike them, including any condition or disorder related to glucosemetabolism disorders. In certain embodiments, compositions of thepresent invention, and methods of using the same, are provided forpreventing, reducing or treating in animal subjects (including humansand other mammals) one or more of the following physiologicalconditions: insulin resistance (the sensitivity of the cellular responseto insulin), beta cell attrition, hyperinsulinemia, hyperglycemia,hepatic gluconeogenesis, onset of diabetes or diabetic symptoms,elevated HbA1c levels, and elevated or inappropriately controlled bloodglucose levels. In certain embodiments, the present invention abates, orotherwise reduces the severity of, diabetes and other glucose metabolismdisorders, including Type 1, Type 2, MODY, and IGT, and any relatedsequelae, including, for example, obesity, obesity-related hypertension,retinopathy, nephropathy, neuropathy, cataracts, coronary artery diseaseand arteriosclerosis. In certain embodiments, subject compositionscontain one or more anti-diabetic agents and one or more othercomponents. Such anti-diabetic agents and other such components may ormay not be administered together or by the same means.

In other embodiments, the present invention provides supplements orcompositions, and methods of using the same, for regulating, modulatingor altering lipid metabolism in a manner beneficial to the patient. Forexample, the subject compositions, and methods of using the same, can beused to modulate at least one of body fat stores, blood pressure,hyperlipoproteinemia, hypertriglyceridemia, serum cholesterol level, HDLlevel and LDL level. In certain embodiments, the present inventionabates or otherwise reduces the severity of dyslipidemia,atherosclerosis and CHD. In still other embodiments, the presentinvention provides compositions and supplements, and methods for usingthe same, to reduce appetite for cosmetic purposes or treatment ofillness, dysfunction or obesity.

In certain embodiments, the present invention provides supplements orcompositions containing an anti-diabetic agent and at least anothercomponent, and methods of using the same, for the long-term reductionand abatement of at least one of the foregoing disorders or conditionsbased on a therapeutic regimen. In certain aspects, the presentinvention contemplates monitoring such disorders or conditions as partof any therapeutic regimen, which may be administered over theshort-term and/or long-term.

In certain embodiments, the invention compositions include at least atherapeutically effective amount of chromium and an anti-diabetic agent.In other embodiments, the invention compositions include at least atherapeutically effective amount of vanadium and an anti-diabetic agent.In still other embodiments, the present invention includes both chromiumand vanadium and an anti-diabetic agent. In yet other embodiments, thechromium or vanadium of any composition is a bioavailable source. Inaddition, embodiments of the present invention may include any of theother components set forth herein and others known to those of skill inthe art, including any agents, components or ingredients that arebeneficial in the treatment or prevention of glucose metabolismdisorders or any sequelae related to such disorders.

In some instances, the present invention is designed to regulate any ofthe physiological processes described herein so as to achieve a desiredlevel of a physiological parameter (e.g., a HbA1c level of about 5). Incertain embodiments, such a result is achieved without subjecting apatient to elevated levels of such a parameter. Such embodiments of theinvention may prove useful in preserving health or reducing, preventingor delaying the on set of diabetes or diabetic symptoms without thepatient experiencing the full thrust of such medical conditions. Theseaspects of the invention are particularly helpful in preventive careregimes.

In another aspect of the present invention, the subject compositions orsupplements may be used in the manufacture of a medicament to treat anyof the foregoing conditions or diseases. In certain embodiments, thepresent invention is directed to a method for formulating compositionsor supplements of the present invention in a pharmaceutically acceptableexcipient. In still other embodiments, the present inventioncontemplates compositions or supplements of the present invention forthe treatment any of the foregoing conditions of diseases. It ispreferred that each of the supplements and anti-diabetics are formulatedas a tablet, capsule or other appropriate ingestible formulation, toprovide a therapeutic dose in 10 tablets or fewer. It is moreparticularly preferred that a therapeutic dose is provided in fivetablets or fewer, and it is most particularly preferred that atherapeutic dose is provided in three tablets or fewer.

In yet another aspect of the present invention, the use of a medicamentfor the treatment of a glucose metabolism disorder is provided whereby asufficient amount of an inventive medicament is provided for treatmentof a particular condition and instructions are provided to the patientfor the desired medical treatment regimen. In particularly preferredembodiments, both an anti-diabetic agent and a supplement are provided,and the patient is instructed to ingest these concurrently.

In part, the present invention is directed to a dietary supplement thatmay be formulated for people individuals in an increased risk categoryas identified by any number of risk factors, including familial history.In certain embodiments, an object of the present invention is to screensubjects for a genetic predisposition to glucose metabolism disorders,such as IGT, Type 2 diabetes, or MODY, in order to begin administrationof the supplements or compositions of the present invention, or methodsof using the same, or programs thereof, to prevent or alleviate suchdisorders.

In another embodiment of the invention it will be desirable to includemonitoring or diagnostic regimes or kits with composition or methodsbased on mineral and vitamins products described herein, andinstructions for use of these compositions or methods.

In other embodiments, the present invention contemplates programs forprevention or treatment of any of the foregoing disorders or conditions.In some embodiments of such programs, one or more physiologicalparameters will be measured, and dosing and/or composition of supplementwill be varied to reflect the health of the individual. Certain programsrequire that the patient ingest the supplement for a minimum timeperiod, whereupon the same physiological parameters will be measuredagain to determine what affect the supplement may have caused. Incertain embodiments, the programs call for changes in dosing,components, or formulation of the supplement depending on the resultsreported after an initial trial period on a program. In certainembodiments, programs of the present invention may require monitoring bythe patients or additional treatment or prevention activities, such asdietary recommendations or exercise suggestions. In addition, in certaininstances, the programs may include instructions for the patientsconcerning the scope and purpose of the program.

DETAILED DESCRIPTION OF THE INVENTION

1. Definitions

For convenience, before further description of the present invention,certain terms employed in the specification, examples, and appendedclaims are collected here. These definitions should be read in light ofthe rest of the disclosure and understood as by a person of skill in theart.

The term “anti-diabetic agent” shall mean any drug that is useful intreating, preventing, or otherwise reducing the severity of any glucosemetabolism disorder, or any complications thereof, including any of theconditions, disease, or complications described herein. Anti-diabeticagents include insulin, thiazolidinediones, sulfonylureas, benzoic acidderivatives, alpha-glucosidase inhibitors, or the like. Other generalcategories of anti-diabetic agents which may be part of a subjectcomposition include (with defined terms being in quotation marks): “drugarticles” recognized in the official United States Pharmacopoeia orofficial National Formulary (or any supplement thereto); “new drug” and“new animal drug” approved by the FDA of the U.S. as those terms areused in Title 21 of the United States Code; any drug that requiresapproval of a government entity, in the U.S. or abroad (“approveddrug”); any drug that it is necessary to obtain regulatory approval soas to comply with 21 U.S.C. §355(a) (“regulatory approved drug”); anyagent that is or was subject to a human drug application under 21 U.S.C.§379(g) (“human drug”). (All references to statutory code for thisdefinition refer to such code as of the original filing date of thisApplication.) Other anti-diabetic agents are disclosed herein, and areknown to those of skill in the art. It is preferred that the inventiveanti-diabetic compositions, as used herein, are capable of reducingHbA1c levels by at least a 10% change from the baseline, and it is moreparticularly preferred that the inventive anti-diabetic compositions, asused herein, are capable of reducing HbA1c levels by at least a 50%change from the baseline.

The term “bioavailable” means that a compound, composition, supplement,component, or material is in a form that allows for it, or a portion ofthe amount administered, to be absorbed by, incorporated to, orotherwise physiologically available to a subject to whom it isadministered. In certain embodiments of the present invention,bioavailable sources of components of supplements or compositions of thepresent invention containing a transition metal, including chromium,vanadium, are contemplated, as discussed in more detail herein.

An embodiment of the invention is said to have an “insulinotropicactivity” if it is able (i) to stimulate, or cause the stimulation of,the synthesis or expression of the hormone insulin, or (ii) to increasethe half-life or the apparent potency of insulin in vivo. Insulin may beany naturally occurring form of the polypeptide, or any form of insulin,including any polypeptide that achieves the same effect of insulin,administered to a patient.

The phrases “parenteral administration” and “administered parenterally”means modes of administration other than enteral and topicaladministration, usually by injection, and includes, without limitation,intravenous, intramuscular, intraarterial, intrathecal, intracapsular,intraorbital, intracardiac, intradermal, intraperitoneal, transtracheal,subcutaneous, subcuticular, intra-articulare, subcapsular, subarachnoid,intraspinal and intrasternal injection and infusion.

The term “modulation” as used herein refers to both upregulation (i.e.,activation or stimulation) and downregulation (i.e. inhibition orsuppression) of a response, or the two in combination or apart.

The phrase “pharmaceutically acceptable” refers to those supplements,components, materials, compositions, and/or dosage forms which are,within the scope of sound medical judgment, suitable for use in contactwith the tissues of human beings and animals without excessive toxicity,irritation, allergic response, or other problem or complication,commensurate with a reasonable benefit/risk ratio.

The phrase “pharmaceutically-acceptable carrier” as used herein means apharmaceutically-acceptable material, composition or vehicle, such as aliquid or solid filler, diluent, excipient, solvent or encapsulatingmaterial, involved in carrying or transporting any supplement orcomposition, or component thereof, from one organ, or portion of thebody, to another organ, or portion of the body. Each carrier must be“acceptable” in the sense of being compatible with the other ingredientsof the supplement and not injurious to the patient. Some examples ofmaterials which may serve as pharmaceutically-acceptable carriersinclude: (1) sugars, such as lactose, glucose and sucrose; (2) starches,such as corn starch and potato starch; (3) cellulose, and itsderivatives, such as

carboxymethyl cellulose, ethyl cellulose and cellulose acetate; (4)powdered tragacanth; (5) malt; (6) gelatin; (7) talc; (8) excipients,such as cocoa butter and suppository waxes; (9) oils, such as peanutoil, cottonseed oil, safflower oil, sesame oil, olive oil, corn oil andsoybean oil; (10) glycols, such as propylene glycol; (11) polyols, suchas glycerin, sorbitol, mannitol and polyethylene glycol; (12) esters,such as ethyl oleate and ethyl laurate; (13) agar; (14) bufferingagents, such as magnesium hydroxide and aluminum hydroxide; (15) alginicacid; (16) pyrogen-free water; (17) isotonic saline; (18) Ringer'ssolution; (19) ethyl alcohol; (20) phosphate buffer solutions; and (21)other non-toxic compatible substances employed in pharmaceuticalformulations.

The term “pharmaceutically-acceptable salts” refers to the relativelynon-toxic, inorganic and organic acid addition salts of components ofcompositions of the present invention.

The phrases “systemic administration,” “administered systemically,”“peripheral administration” and “administered peripherally” mean theadministration of a subject supplement, composition, therapeutic orother material other than directly into the central nervous system, suchthat it enters the patient's system and, thus, is subject to metabolismand other like processes, for example, subcutaneous administration.

The phrase “therapeutically-effective amount” means that amount ofsupplement or composition which is effective for producing some desiredtherapeutic effect by, for example, modulating glucose metabolism at areasonable benefit/risk ratio applicable to any medical treatment.

2. General Introduction

The present invention provides methods and compositions for modificationand regulation of glucose and lipid metabolism, generally to reduceinsulin resistance, hyperglycemia, hyperinsulinemia, obesity,dyslipidemia, hyperlipoproteinemia (such as VLDL), and to regulate bodyfat and more generally lipid stores, and, more generally, to improve ofmetabolism disorders, especially those associated with diabetes,obesity, atherosclerosis, or CHD.

For instance, in certain embodiments of the preset invention,administration of a subject supplement or composition, or methods ofusing the same, in an effective amount improves one or more aberrantindices associated with glucose metabolism disorders (e.g., glucoseintolerance, insulin resistance, hyperglycemia, hyperinsulinemia,diabetic dyslipidemia, and Type 2 diabetes). In other embodiments,administration of a subject supplement, or methods thereof, in aneffective amount improves aberrant indices associated with CHD orobesity.

In other embodiments, the supplements and compositions haveanti-diabetic activities, and may be used in the treatment of disordersmarked by aberrant glucose metabolism (including storage). In certainembodiments, supplements or compositions, or components thereof, of thepresent invention are useful as insulin enhancing or insulinotropicagents. The subject compositions or methods may be useful for thetreatment and/or prophylaxis of a variety of disorders, including one ormore of dyslipidemia, hyperglycemia, obesity, glucose toleranceinsufficiency or impairment, insulin resistance, and diabeticcomplications.

In certain embodiments, the invention compositions include one or moreanti-diabetic agents and one or more components described herein. Incertain embodiments, such component constitutes a therapeuticallyeffective amount of a bioavailable source of chromium. In otherembodiments, such component constitutes a therapeutically effectiveamount of a bioavailable source of vanadium. In still other embodiments,the present invention is directed towards a supplement or compositioncontaining one or more additional components from the following group:magnesium, vitamin E, aspirin; alpha-lipoic acid; and folic acid.

In one embodiment, a supplement includes an effective amount of chromiumpolynicotinate and/or chromium picolinate as the chromium source, aneffective amount of vanadyl sulfate as the vanadium source, an effectiveamount of magnesium as a either a complex of chloride or Krebs (citrate,fumarate, malate, glutarate or succinate), an effective amount of free2R, 4′R, 8′R-alpha-tocopherol as the vitamin E source, or anothereffective source of vitamin E, an effective amount of standardizedwillow bark, an effective amount of folic acid and alpha-lipoic acid, aswell as sufficient amounts of other vitamin and mineral sources.

In another aspect, the present invention is directed to supplements orcompositions capable of preventing, treating, or otherwise reducing theseverity of disorders of glucose metabolism. Insulin resistance is thepathophysiologic indicator of patients with IGT and Type 2 diabetes,which often occurs many years before clinically evident disease ispresent. As peripheral glucose use decreases, subjects may remaineuglycemic, but hyperinsulinemic, as long as beta cells maintainsufficient insulin concentrations. Eventually, insulin resistance andrising plasma glucose levels

insulin production. The disease or condition progresses from insulinresistance with hyperinsulinemia to impaired glucose tolerance,resulting in modest increases in post-prandial glucose concentrations,followed by clinical diabetes and hyperglycemia. The supplements andcompositions of the present invention, and methods of using the same,are intended to delay the onset of Type 2 diabetes and its associatedsequelae by addressing disorders of glucose metabolism at an earlystage.

The present invention also provides methods for enhancing the naturalcontrol of blood glucose levels in a person by daily administration ofthe subject composition and nutritional supplement. The presentinvention contemplates administration of a supplement of the presentinvention to control the blood sugar by reducing insulin resistance indiabetic and IGT patients, thereby preventing the chronic complicationsfrom developing in these high risk patients. There is also a need toprovide an effective supplement for the treatment of diabetes and itssymptoms prior to the onset of full-blown diabetes.

With respect to GDM, studies of insulin action and beta-cell functionduring pregnancy indicate that, during the third trimester, women withmild-moderate GDM have the same degree of insulin resistance as donon-diabetic pregnant women. However, studies during the secondtrimester and after pregnancy indicate that women with GDM are somewhatinsulin resistant compared to women who maintain normal glucosetolerance during pregnancy. The main feature that distinguishes womenwith GDM from normal pregnant women during the third trimester, when allwomen are insulin resistant, is pancreatic beta-cell function. Mostwomen develop GDM because their pancreatic beta-cells are unable tomaintain enhanced insulin secretion in the face of insulin resistance.That inability is very similar to the beta-cell defect which has beenobserved in longitudinal studies of patients who develop Type 2diabetes, a fact which may explain why women with GDM are at such highrisk for Type 2 diabetes. GDM identifies women whose beta-cells willdecompensate when faced with severe or chronic insulin resistance.

In another aspect, the present invention also provides for kitscontaining at least one dose of a subject supplement or composition, andoften many doses, and other materials for a treatment regimen. Forexample, in one embodiment, a kit of the present invention containssufficient subject composition for thirty days and equipment andsupplies necessary to measure one or more indices relevant to glucosemetabolism, such as blood glucose levels. In another embodiment, kits ofthe present invention contain all the materials and supplies, includingsupplements and compositions, for carrying out any methods of thepresent invention. In still another embodiment, kits of the presentinvention, as described above, additionally include instructions for theuse and administration of the supplements and compositions.

In another aspect, the present invention provides for programs wherebythe supplements or compositions of the present invention are ingested bya subject having a condition described herein, including subjects thatare pre-diabetic. The program format of the present invention allows fora variety of variables to be addressed in providing composition andsupplements of the present invention. Some of these variables include:one or more conditions to be addressed by any one program, compositionsand supplements to be used in any such program, and dosing regimen ofany such program. In certain instances, a program may include a kit ofthe present invention.

Many of the features of any program, including for example the dosingregimen, may be provided for in instructions to the subjectparticipating in any program. Such instructions may, in certainembodiments, require the subject to decide whether to continue anyprogram depending on the results obtained while on the program. Thelength of such trial period may vary with the particular program.Typically, trial periods may be between about one to about six or moremonths, and alternatively, the trial periods may be between one andthree months.

In certain embodiments of such programs, the subject may be required toassess their progress on the program by monitoring a parameter relevantto their particular condition. In certain embodiments, a programdirected to prevention or treatment of a glucose metabolism disordersmay require subjects to monitor their HbA1c levels. After a certainperiod on such a program, during which the subject would have used thecomposition or supplement prescribed by the program in the mannerdictated thereby, the program may require the subject to determine theirHbA1c level. Depending on whether the HbA1c level changed by aparticular amount, the subject may continue with the particular program,discontinue the program altogether, or alter the program. The foregoingdecision may depend on the initial condition of the subject.

For example, in one embodiment of a program of the present invention,the dose of chromium administered to a patient in a composition varieswith the initial HbA1c level. Accordingly, in this particular example,the chromium dosages would be as follows: for a patient having an HbAlclevel in the range of about 7 up to about 8, a dose of chromium is inthe range of about 0.003 mg Cr or less/kg of body weight up to about0.009 mg Cr or less/kg, for a patient having an HbA1c level in the rangeof about 8 up to about 9, a dose of chromium is in the range of about0.005 mg Cr/kg of body weight up to about 0.01 mg Cr/kg of body weight,for a patient having an HbA1c level in the range of about 10 up to about11, a dose of chromium is in the range of about 0.006 mg Cr/kg of bodyweight up to about 0.01 5 mg Cr/kg of body weight, and for a patienthaving an HbA1c level in the range of at least about 11, a dose ofchromium in the range of about 0.007 mg Cr/kg of body weight up to about0.04 mg Cr or more/kg of body weight. The particular dose of chromiumwould be maintained for a trial period, whereupon the HbA1c level wouldbe measured again. If the patient's HbA1c level had dropped during thetrial period, then the dose of chromium ingested could be reduced; ifthe HbA1c level had not decreased, the patient would have a number ofoptions: the dose of chromium could be increased, the same dose could beingested for a longer time period, or a different chromium complex withpotentially differing bioavailability and potency for the particularindividual could be used. This program could be applied to any othercomponent or ingredient of the present invention, including, forexample, any vanadium containing complex.

In addition to those indices already discussed above, a number ofparameters of blood serum may be measured to assess the efficacy of anysupplement or method of the present invention in attending to theconditions described herein. Any of these parameters may serve as thebasis of a program of the present invention. Useful parameters include:LDL-cholesterol, HDL-cholesterol, apolipoprotein A1, apolipoprotein B,HbA1c, and blood sugar level (fasting, post-prandial and urine). It hasbeen observed that the subject compositions are especially effective inimproving blood glucose control after eating, so the post-prandialmeasurement may be preferred in certain embodiments of the presentinvention.

Other measurements of import for any subject invention include heartrate, blood pressure, weight, and temperature. To assess the presentinvention's affect on a patient's body condition, the following may bemonitored: various skin-fold thicknesses, bicep and calf circumferences,body weight, lean body mass, percent body fat, body mass index (BMI),and waist-to-hip ratio (WHP).

The amounts of the individual components of preparations of thisinvention may vary, although in certain preparations the components arepresent in amounts lying within certain ranges presented herein. Thepresent invention typically contemplates administering the dosages ofany supplement or composition on a daily basis, or at other frequenciesappropriate to the supplement or composition and its mode of delivery.For example, a dose of a composition of the present invention may beingested or administered daily in a single serving, e.g., a tablet or aliquid, or in multiple servings. Alternatively, the dosages of thepresent invention may be ingested over a several day period or over anyother time period so as to achieve the desired therapeutic effects.

Certain supplements and compositions of the present inventioncontemplate components that are transition metal chelates. Certain ofthe metal chelates contemplated by the present invention may have, inaddition to any chelating ligand or ligands that are bound covalently orthrough ionic interactions to said metal ion, a counter-ion that isgenerally not bound to the metal ion (or if associated, only weakly so),and counters any charge of the metal-ligand complex. For example, invanadyl sulfate hydrate, the sulfate would generally be considered acounter-ion to the vanadyl ion metal-ligand complex. Some examples ofcommonly encountered counter-ions include sulfate, perchlorate, nitrate,halogens, and the like. In addition, the metal chelates may have anumber of waters of hydration associated with them. For example, oneform of magnesium dichloride is magnesium dichloride hexahydrate, inwhich six waters of hydration are part of the metal complex. A metalchelate that is identified as an hydrate may have one or more waters ofhydration. In addition, the number of molecules of waters of hydrationmay be a non-integer number when expressed as a ratio of one molecule ofmetal complex to the molecular number of the waters of hydration.

In providing a dose of transition metal chelate to a subject, the mostappropriate dose may depend, in part, on the nature of the metalchelate. Certain transition metal or mono- or multi-valent ion complexesmay be more readily assimilated than others, and may therefore be moreeffective in achieving the desired therapeutic response than othercomplexes. Another important factor may be the water solubility of anymetal complex. Another relevant factor may be the mode ofadministration. Consequently, dosages of the complexes typicallycontemplated by the present invention usually depend on the identity ofthe complex, the means of administration, and the formulation in whichthe complex is administered.

For instance, chromium picolinate appears to be absorbed at a rate aboutfour times greater than chromium trichloride upon oral administration torats. Usually, a chromium picolinate is preferred

chromium trichloride as the administered complex. In other embodiments,chromium polynicotinate will be preferred over chromium picolinate as itcontemplated that chromium polynicotinate will generally have betterabsorption and metabolic properties than chromium picolinate.

For many transition metal chelates (or other metal chelates), such asthose contemplated by the present invention, the metal chelate or otherinorganic complex administered to a subject may differ from the formthat is responsible for any biological activity. Furthermore, manydifferent complexes of the same transition metal may cause a biologicalresponse to different degrees. For instance, a transition metal complexmay undergo any number of reactions in vivo, including: hydrolysis,which depends greatly on pH conditions; redox reactions, whereby thetransition metal, or even a chelating ligand, may change electronicstate, which depends greatly on the local redox environment; and otherligation reactions, whereby a molecule may, because of, for example,superior binding characteristics and/or affinity or greaterconcentration, displace a ligand chelating the metal. It is not uncommonfor a transition metal complex, especially those containing first rowtransition metals, to undergo complete hydrolysis upon ingestion oradministration to a subject and possibly chelation by a molecule presentin vivo. Generally, complexed forms of such metals will be selected todirect or maintain the desired form of the metal in the body. Otherpotentially desirable characteristics in metal complexes include: aneutral charge to the complex, sufficient water solubility (e.g.,capable of forming an at least a 0.1 mM solution); and capable of beingabsorbed orally and gastro-intestinally.

For the different transition metals that serve as components in thesubject supplements, particular complexes are discussed in more detailherein. In addition, acceptable salts of such transition metals that mayserve as components in the subject preparations generally include theconventional non-toxic salts of the compounds, e.g., salts derived fromnon-toxic organic or inorganic acids. For example, such conventionalnon-toxic salts include those derived from inorganic acids such ashydrochloride, hydrobromic, sulfuric, sulfamic, phosphoric, nitric, andthe like; and the salts prepared from organic acids such as acetic,propionic, succinic, glycolic, stearic, lactic, malic, tartaric, citric,ascorbic, palmitic, maleic, hydroxymaleic, phenylacetic, glutamic,benzoic, salicyclic, sulfanilic, 2-acetoxybenzoic, fumaric,toluenesulfonic, methanesulfonic, ethane disulfonic, oxalic, isothionic,valeric, oleaic, lauric, lactic, lactobionic, laurylsulphic, and thelike. See, for example, Berge et al. J. Pharm. Sci. 66:1-19 (

-7). For the different transition metal or other metal complexes of thepresent invention described herein, the dosages are presented withreference to the amount of elemental transition metal or other metal insuch complex, unless otherwise expressly indicated or implied by thecontext.

Contemplated equivalents of the components of the subject compositionsof the present invention include compounds or materials that otherwisecorrespond thereto, and which have the same general properties thereof,wherein one or more simple variations of substituents are made which donot adversely affect the efficacy of the compound in the composition orin use in the contemplated method.

As explained herein in greater detail, the invention will readily enablethe design and implementation of trials in warm-blooded animals,including humans and mammals, necessary for easily determining ortailoring the form and dose for any supplement, and the componentsthereof, of the present invention.

3. Exemplary Compositions and Methods of Using the Same

The present invention provides in part for dietary supplements orcompositions that enhance glucose metabolism. In certain embodiments,one or more of the components of the subject composition may beresponsible for such enhancement. Preferably, embodiments of theinvention include supplements or compositions that enhance glucosemetabolism, while treating or reducing the severity of many of thesecondary or risk factors that often accompany diabetes or IGT. Althoughthe subject supplements or compositions may be used by individuals withno apparent symptoms of diabetes, the supplement is particularly suitedfor use by individuals with IGT and/or diabetes to prevent, reduce oreliminate the necessity of using insulin. The present invention alsocontemplates using the formulations in conjunction with other methods oftreating diabetic and pre-diabetic individuals, or otherwise reducingthe severity of their condition. For example, the formulations of thepresent invention may contain other ingredients such as anti-diabeticagents that work with insulin to enhance the effect of insulin on theregulation of glucose concentration in the blood by improving metabolismof glucose in the insulin sensitive cells of the body.

Without limiting the invention to a particular mechanism of action, bothchromium and vanadium may act at two different levels in the body: 1)gastrointestinal tract activity, particularly localized to theintestine; and 2) systemic activity. These two levels of action are atthe organ level

include additional effects at the cellular and subcellular level.

In the gastrointestinal tract, chromium and vanadium (eitherindividually, or preferably in concert) modulate sugar transport (e.g.,glucose transport) by typically slowing glucose absorption. Slowerglucose absorption slows insulin release and reduces excessive insulinresponses in response to rising blood glucose levels after a meal. Thisbenefits pancreatic secretion of insulin by reducing both the glucoseload and rate of glucose load over the initial phases of glucosedetection, absorption and metabolism by the body. Reduced rates ofglucose loading reduces the stress on beta cells normally associatedwith the insulin response to rising glucose.

Moreover, slower or modulated glucose absorption permits more time forinsulin to stimulate normal sugar metabolic routes either before glucoseloading is complete, or during a slower rate of glucose loading.Consequently, insulin dependent mechanisms have more time to prepare forthe arrival of sugars from the intestine. This modulation of glucoseabsorption improves short-term insulin modulation in the liver, muscle,and adipose tissue. These effects in the gastrointestinal tract are, inall likelihood, short-term responses, and they are not necessarilyassociated with the longer-term systemic effects of chromium andvanadium administration.

In addition, chromium and vanadium may potentially slow glucosemetabolism by interacting with the intestine, particularly theepithelium of the intestine responsible for sugar metabolism (includingabsorption). One primary mechanism for sugar transport in the gut issodium facilitated sugar transport. Such transporters are located in thelumenal membrane of the epithelium. The basolateral membrane may alsohave an additional sugar transporter that facilitates transport out thecell and into the blood. For net sugar absorption from the lumen of thegut to the blood, sodium facilitated sugar transport generally requiresa sodium concentration favorable to the diffusion of sodium into theepithelium cell from the lumen. This concentration gradient is largelygenerated by the active transport of the Na/K ATPase in the epitheliumcells, which generally transports three sodium atoms out of the cell tothe blood side of the epithelium in exchange for two sodium atoms in thereverse direction.

Each cycle of the pump requires hydrolysis of one ATP to transportsodium and potassium against their respective concentration gradients.The hydrolysis reaction requires a divalent cation, typically magnesium.In many instances, however other divalent cations may substitute orenter into the hydrolysis reaction with varying degrees of catalyticactivity or inhibition. Substitution of trivalent cations for divalentcations in the cycle generally leads to significant inhibition of thepumping activity and/or dephosphorylation from the phosphoenzymeintermediate state. Chromium may thus inhibit the Na/K ATPase activityby substituting for magnesium and thereby inhibiting relative tomagnesium catalytic and transport activity giving rise to a decreasedsodium gradient across the lumenal membrane. The reduced gradienteffects sugar transport by reducing the thermodynamic and kinetic forcesfavoring sugar entry from the gut.

In addition, during the hydrolysis of ATP in the catalytic cycle of theNa/K ATPase, a phosphoenzyme intermediate (EP) is formed betweenphosphate and an aspartic acid at the active site of APTase. Thiscovalent EP is transient and is chemical distinct from phosphorylatedproteins associated with kinases and phosphatases, which have also beenshown to be affected by vanadium. Formation of EP in the catalytic cyclefor Na/K ATPase is inhibited by vanadate present at low concentrationsof less than 1 micromolar. Vanadate binds to the active site as atransition state analog of phosphate in a vanadyl-enzyme, or EV complex,rather than EP. The EV complex is highly stable, as vanadate thekinetics of loss of vanadate from the EV complex is relatively slow.Vanadate may thus effectively inhibit the Na/K ATPase by disruptingcatalysis through the formation of EV giving rise to a decreased sodiumgradient across the lumenal membrane. Consequently, the reduced gradientreduces sugar entry from the intestine.

Chromium and vanadium also operate at the systemic level afterabsorption of the two transition metals from the gut. Major sites ofactivity include the liver, muscle and adipose tissue. Vanadium may haveparticular activity with respect to phosphorylation systems, includingthe many phosphorylated proteins responsible for modulating metabolism.Chromium may also modulate metabolism at the cellular level. Thesesystemic effects generally improve the action of insulin and/ormetabolic pathways associated with sugar and/or lipid metabolism.

The dosing for chromium and vanadium components in the subjectcompositions and methods may depend in part on the mechanisms of actiondiscussed above. Both chromium and vanadium may be stored in long term(e.g., about 2 to 6 weeks) compartments which may provide diffusablesites of chromium and vanadium for maintaining elevated levels ofchromium and vanadium in a patient. In treatment, it may be possible toload such sites with chromium or vanadium and then taper or abate thedose of the transition metals over time to allow the deposits to bereduced. The deposit sites may then be reloaded

the tapering repeated as necessary.

In certain embodiments of the invention, it may be desirable to tailordosing of chromium and vanadium to the (as well as other componentsdescribed herein) caloric intake. By combining ingestion of chromium orvanadium with caloric intake, for instance, more desirable absorptionand metabolic patterns of caloric sources, particularly sugars, may beachieved. The short-term effects attributable to chromium and vanadiummay, in particular, beneficially modulate absorption and metabolism.

In regard to absorption and metabolism of the subject compositions, andthe different components thereof, features of the alimentary tract mayaffect how compositions of the present invention, and methods of usingthe same, are utilized when ingested orally. The elements of thealimentary tract, including the gastrointestinal tract, may affect thedosage required for any such modality. Such features are well known tothose of skill in the art.

5 3.1 Anti-Diabetic Agents

Current drugs or anti-diabetic agents used for managing diabetes and itsprecursor syndromes, such as insulin resistance, that are well-known inthe art fall within five classes of compounds: the biguanides,thiazolidinediones, the sulfonylureas, benzoic acid derivatives andglucosidase inhibitors. The biguanides, e.g., metformin, are believed toprevent excessive hepatic gluconeogenesis. The thiazolidinediones arebelieved to act by increasing the rate of peripheral glucose disposal.The sulfonylureas, e.g., tolbutamide and glyburide, and the benzoic acidderivatives, e.g. repaglinide, lower plasma glucose by stimulatinginsulin secretion.

In addition to these agents, a number of other therapies may be used incombination with the supplements of the present invention to improveglucose control. Certain of these anti-diabetic agents have not yet beenapproved for human use.

Among biguanides useful as diabetic therapeutic agents, metformin hasproven particularly successful. Metformin(N,N-dimethylimidodicarbonimidicdiamide; 1,1-dimethylbiguanide;N,N-dimethylbiguanide; N,N-dimethyldiguanide;N′-dimethylguanylguanidine) is an anti-diabetic agent that acts byreducing glucose production by the liver and by decreasing intestinalabsorption of glucose. It is also believed to improve the insulinsensitivity of tissues elsewhere in the body (increases peripheralglucose uptake and utilization). Metformin improves glucose tolerance inimpaired glucose tolerant (IGT) subjects and Type 2 diabetic subjects,lowering both pre- and post-prandial plasma glucose. Metformin isgenerally not effective in the absence of insulin. Bailey, Diabetes Care15:755-72 (1992).

Unlike other agents for treating diabetes, such as the sulfonylureas,metformin does not appear to produce hypoglycemia in either diabetic ornon-diabetic subjects. With metformin therapy, insulin secretion remainsunchanged while fasting insulin levels and day-long plasma insulinresponse may decrease. The efficacy of metformin has been shown inseveral trials. In one study of moderately obese Type 2 diabetics, HbA1clevels improved from 8.6% to 7.1% after 29 weeks of metformin therapyalone or in combination with sulfonylurea. DeFronzo et al., New Engl. J.Med. 333:541-49 (1995). Metformin also had a favorable effect on serumlipids, lowering mean fasting serum triglycerides, total cholesterol,and LDL cholesterol levels and showing no adverse effects on other lipidlevels. In another trial, metformin improved glycemic control in NIDDMsubjects in a dose-related manner. After 14 weeks, metformin 500 and2000 mg daily reduced HbA1c by 0.9% and 2.0%, respectively. Garber etal., Am J. Med. 102:491-97 (1997).

Metformin may have a beneficial therapeutic effect on insulin resistantnon-diabetics. One study indicated that treatment of hypertensive obesenon-diabetic women with metformin decreased blood pressure, fasting andglucose-stimulated plasma insulin fibrinogen. Giugliano et al., DiabetesCare 16:1387-90 (1993).

Metformin is commonly administered as metformin HCl. This as well as allother useful forms of metformin are contemplated for use in the practiceof the present invention. Generally, a fixed dosage regimen isindividualized for the management of hyperglycemia in diabetes withmetformin HCl or any other pharmacologic agent. Individualization ofdosage is made on the basis of both effectiveness and tolerance, whilegenerally not exceeding the maximum recommended daily dose of 2550 mg.In one embodiment of the present invention, compositions comprise in therange of about 10 mg up to about 2550 mg per daily dose. Many patientsobserve benefits at 500 mg per day. In some embodiments of theinvention, dosages may be less than 1000 mg per day when administeredwith the other components of any supplement of the present invention.Some subject experience gastrointestinal side effects, which may bealleviated by dosage reduction. A rare but severe side effect ofmetformin therapy is lactic acidosis.

In combination therapy, metformin is often used with sulfonylureas,alpha-glucosidase inhibitors, troglitazeon, and insulin. Metformincombined with a sulfonylurea increases insulin sensitivity and may lowerplasma glucose. Alternatively, metformin with repaglinide may be moreeffective than glipizide, and at least as effective as glyburide, inmaintaining glycemic control over many months. Metformin withtroglitazone improves glucose control in excess of either agent alone.Inzucchi et al., New. Eng. J. Med. 338:867-72 (1998).

Thiazolidinediones contemplated for use in the practice of the presentinvention include troglitazone, and the like. Such compounds arewell-known, e.g., as described in U.S. Pat. Nos. 5,223,522, 5,132,317,5,120,754, 5,061,717, 4,897,405, 4,873,255, 4,687,777, 4,572,912,4,287,200, and 5,002,953; and Current Pharmaceutical Design 2:85-101(1996). Troglitazone is an oral antihyperglycemic agent that increasesglucose transport possibly by activation of peroxisomeproliferator-activated receptor-γ (PPARγ). By such activation,troglitazone enhances expression of GLUT4 glucose transporters,resulting in increased insulin-stimulated glucose uptake. Troglitazonemay also attenuate gluconeogenesis and/or activation of glycolysis.

Glycemic control resulting from troglitazone therapy reduces HbA1c byapproximately 1 to 2%. Mimura et al., Diabetes Med. 11:685-91 (1994);Kumar et al., Diabetologia 39:701-09 (1996). Effects may not occur for afew weeks after beginning therapy. Troglitazone may also decreaseinsulin requirements. In one trial of patients with NIDDM and usingexogenous insulin, mean HbA1c fell by 0.8% and 1.4% for doses of 200 and600 mg troglitazone, respectively. Insulin requirements were reduced byup to 29%. Schwartz et al., New Engl. J. Med. 338:861-66 (1998). Inanother study of NIDDM diabetics using 400 and 600 mg troglitazone,fasting and post-prandial glucose levels were decreased, andhyperinsulinemic euglycemic clam indicated that glucose disposal wasapproximately 45% above pretreatment levels. Maggs et al., Ann. Intern.Med. 128:176-85 (1998). For all these studies, triglycerideconcentrations are lowered and HDL increased, whereas LDL may or may notbe increased. Troglitazone does not appear to cause hypoglycemia duringmonotherapy, but it may result when troglitazone is used in combinationwith insulin or a sulfonylurea.

Troglitazone may be used to delay or prevent Type 2 diabetes in certainembodiments of the present invention. In one study, 400 mg oftroglitazone increased glucose disposal rates in obese patients witheither impaired or normal glucose tolerance. Nolan et al., New Eng. J.Med 331:1188-93 (1994). In another study of women with IGT and a historyof gestational diabetes, 600 mg troglitazone improved insulinhomeostasis, including improving insulin sensitivity and loweringcirculating insulin concentrations, but glucose tolerance was unchanged.Berkowitz et al., Diabetes 45:172-79 (1996). Thiazolidinediones may beused with at-risk populations for NIDDM, such as women with POCS or GDM,to prevent or delay the onset of NIDDM. U.S. Pat. No. 5,874,454.

Effective amounts of troglitazone, when used alone, range from about 10mg up to about 800 mg per daily dose and a commensurate range iscontemplated for use in the present invention. In certain aspects of thepresent invention, the composition comprises from about 100 mg to about600 mg of troglitazone per daily dose, or alternatively 400 mg. Thedaily dose may subdivided for administration on two, three, or moreoccasions during the day.

In addition to being used with metformin, troglitazone may be used incombination with insulin and a sulfonylurea agent. See, for example,U.S. Pat. No. 5,859,037.

In the present invention, sulfonylureas may be used to treat diabetes.Sulfonylureas generally operate by lowering plasma glucose by increasingthe release of insulin from the pancreas. Specifically, sulfonylureasact by blocking the ATP-sensitive potassium channels. The sulfonylureaglimepiride may also increase insulin sensitivity by stimulatingtranslocation of GLUT4 transporters. Sulfonylureas are typicallyprescribed when HbA1c is above 8%. See also U.S. Pat. Nos. 5,258,185,4,873,080.

The sulfonylureas are a class of compounds that are well-known in theart, e.g., as described in U.S. Pat. Nos. 3,454,635, 3,669,966,2,968,158, 3,501,495, 3,708,486, 3,668,215, 3,654,357, and 3,097,242.Exemplary sulfonylureas contemplated for use in certain embodiments ofthe present invention (with typical daily dosages indicated inparentheses) include acetohexamide (in the range of about 250 up toabout 1500 mg), chlorpropamide (in the range of about 100 up to about500 mg), tolazimide (in the range of about 100 up to about 1000 mg),tolbutamide (in the range of about 500 up to about 3000 mg), gliclazide(in the range of about 80 up to about 320 mg), glipizide (in the rangeof about 5 up to about 40 mg), glipizide GITS (in the range of about 5up to about 20 mg), glyburide (in the range of about 1 up to about 20mg), micronized glyburide (in the range of about 0.75 up to about 12mg), glimeperide (in the range of about 1 up to about 8 mg), AG-EE 623ZW, and the like. Glimepiride is the first anti-diabetic agent in thisclass to be approved for use with insulin, and there may be less risk ofhypoglycemia associated with its use.

A variety of alpha-glucosidase inhibitors may used in certainembodiments of the present invention to treat and/or prevent diabetes.Such inhibitors competitively inhibit alpha-glucosidase, whichmetabolizes carbohydrates, thereby delaying carbohydrate absorption andattenuating post-prandial hyperglycemia. Clissod et al., Drugs 35:214-23(1988). These decrease in glucose allows the production of insulin to bemore regular, and as a result, serum concentrations of insulin aredecreased as are HbA1c levels. There does not appear to be any increasedinsulin sensitivity, however.

Exemplary alpha-glucosidase inhibitors contemplated for use in thepractice of the present invention include acarbose, miglitol, and thelike. Effective dosages of both acarbose and miglitol are in the rangeof about 25 up to about 300 mg daily.

Alpha-glucosidase inhibitors may be used in combination withsulfonylureas, and they appear to be about on-half as effective assulfonylureas or metformin in reducing glucose levels. HbA1c levelsgenerally decrease from 0.5 to 1.0%. In addition, alpha-glucosidaseinhibitors have been shown to be effective in reducing the post-prandialrise in blood glucose. Lefevre et al., Drugs 44:29-38 (1992).

A variety of benzoic acid derivatives may used in certain embodiments ofthe present invention to treat and/or prevent diabetes. These agents,also known as meglitinides, are non-sulfonylurea hypoglycemic agentshaving insulin secretory capacity. For example, repaglinide appears tobind to ATP-sensitive potassium channels on pancreatic beta cells andthereby increases insulin secretion. Exemplary benzoic acid derivativescontemplated for use in the practice of the present invention includerepaglinide and the like. For repaglinide, the effective daily dosagemay be in the range of about 0.5 mg up to about 16 mg, and the agent maybe taken before each meal.

In another illustrative embodiment, the subject supplements may beconjointly administered with a an M1 receptor antagonist. Cholinergicagents are potent modulators of insulin release that act via muscarinicreceptors. Moreover, the use of such agents can have the added benefitof decreasing cholesterol levels, while increasing HDL levels. Suitablemuscarinic receptor antagonists include substances that directly orindirectly block activation of muscarinic cholinergic receptors.Preferably, such substances are selective (or are used in amounts thatpromote such selectivity) for the M1 receptor. Nonlimiting examplesinclude quaternary amines (such as methantheline, ipratropium, andpropantheline), tertiary amines (e.g. dicyclomine, scopolamine) andtricyclic amines (e.g. telenzepine). Pirenzepine and methyl scopolamineare preferred. Other suitable muscarinic receptor antagonists includebenztropine (commercially available as COGENTIN from

), hexahydro-sila-difenidol hydrochloride (HHSID hydrochloride disclosedin Lambrecht et al., Trends in Pharmacol. Sci. 10(Suppl):60 (1989);(+/−)-3-quinuclidinyl xanthene-9-carboxylate hemioxalate(QNX-hemioxalate; Birdsall et al., Trends in Pharmacol. Sci. 4:459(1983); telenzepine dihydrochloride (Coruzzi et al., Arch. Int.Pharmacodyn. Ther. 302:232 (1989); and Kawashima et al., Gen. Pharmacol.21:17 (1990)) and atropine. The dosages of such muscarinic receptorantagonists will be generally subject to optimization as outlined below.In the case of lipid metabolism disorders, dosage optimization may benecessary independently of whether administration is timed by referenceto the lipid metabolism responsiveness window or not.

In terms of regulating insulin and lipid metabolism and reducing theforegoing disorders, the subject formulations or supplements may alsoact synergistically with prolactin inhibitors such as d2 dopamineagonists (e.g. bromocriptine). Accordingly, the subject method mayinclude the conjoint administration of such prolactin inhibitors asprolactin-inhibiting ergo alkaloids and prolactin-inhibiting dopamineagonists. Examples of suitable agents include2-bromo-alpha-ergocriptine, 6-methyl-8beta-carbobenzyloxyaminoethyl-10-alpha-ergoline, 8-acylaminoergolines,6-methyl-8-alpha-(N-acyl)amino-9-ergoline,6-methyl-8-alpha-(N-phenylacetyl)amino-9-ergoline, ergocornine,9,10-dihydroergocornine, D-2-halo-6-alkyl-8-substituted ergolines,D-2-bromo-6-methyl-8-cyanomethylergoline, carbidopa, benserazide andother dopadecarboxylase inhibitors, L-dopa, dopamine and non toxic saltsthereof. Methods of administering prolactin inhibitors have been devisedto minimize the reduction in metabolic rate which may result from suchtherapy. U.S. Pat. Nos. 5,866,584; 5,744,477.

A number of agents are presently under investigation as potentialanti-diabetics in humans. Any of such agents may be used in the presentinvention for treatment and/or prevention of diabetes if they becomeavailable for therapeutic use.

Another category of anti-diabetic agents that is still undergoing safetyand efficacy trials is inhibitors of carnitine palmitoyl-transferase I(CPT-I), such as etomoxir. Subject to its approval for human use,etomoxir and other like agents may be used in certain embodiments of thepresent invention. Etomoxir irreversibly inhibits carnitinepalmitoyl-transferase I, which is necessary for fatty acid oxidation.Such inhibition may reducde fasting hyperglycemia, because products offatty acid oxidation stimulate hepatic gluconeogenesis. Etomoxir mayimprove insulin sensitivity in Type 2 diabetics. Hubinger et al.,Hormone Metab. Res. 24:115-18 (1992). Although early CPT-I inhibitorscaused cardiac hypertrophy in animals, newer inhibitors such as etomoxirmay show less cardiotoxicity.

Another class of anti-diabetic agents that, subject to the necessaryregulatory approval(s), may be used in certain embodiments of thepresent invention, are amylin compounds. Amylin is a 37 amino acidpolypeptide synthesized and secreted along with insulin from beta cells.Early studies indicate that such compounds reduce post-prandialincreases in serum glucose.

Still other anti-diabetic agents that may be used in certain embodimentsof the present invention are dipeptidyl peptidase IV inhibitors andglucagon-like polypeptides (I) (glp I), (glp2), or other diabetogenicpeptide hormones.

3.2 Components of Compositions or Supplements

In certain embodiments, the compositions of the present invention mayaugment or supplant other forms of diabetes and IGT treatment, such asinsulin. In certain embodiments, programs of the present inventionrequire that the subject compliment such treatment methods with thecompositions of the present invention.

In one embodiment of the present invention, it has been discovered thata composition containing an anti-diabetic agent and the followingcomponents in effective amounts and metabolically available forms:vanadium, chromium, magnesium, and vitamin E in combination withnaturally available sources of aspirin, alpha-lipoic acid, and folicacid, improves the metabolism of glucose. Such compositions may be alsoused to arrest, treat or otherwise reduce the severity of many of thecardiovascular complications or risk factors associated with diabetes orpre-diabetes. These components perform different functions which, whenadministered in appropriate dosages and forms, typically enhance themetabolism of glucose

In part, the present invention contemplates combinations ofanti-diabetic agents and components in different supplements orcompositions to produce a therapeutic effect in a patient with a glucosemetabolism disorder, such as Type 2 diabetes, IGT, Syndrome X, insulinresistance, or hyperinsulinemia. In general, the therapeutic effect maybe measured by reference to any number of indices that are directlyrelated to glucose metabolism, such as blood glucose level or HbA1clevel, or other parameters that may otherwise be affected by such adisorder or a related condition or disease. The present inventionteaches how to test supplements or compositions

any one or more of the components set forth herein to determine whetherany particular combination of anti-diabetic agents and components in asupplement or composition results in a desirable therapeutic effect uponadministration to a patient.

In certain embodiments, the subject compositions contain, in addition toan anti-diabetic agent, at least a therapeutically effective amount of abioavailable source of chromium. In other embodiments, the subjectcompositions contain, in addition to an anti-diabetic agent, at least atherapeutically effective amount of a bioavailable source of vanadium.In still other embodiments, the present invention includes, in additionto an anti-diabetic agent, both bioavailable sources of chromium andvanadium.

3.2.1 Chromium

Chromium is a trace mineral found in human tissues. Claims surroundingthe use of chromium as a supplement, such as weight loss and buildingmuscle mass, have been made for non-diabetic individuals.Notwithstanding such claims, the status of chromium supplementation,even for diabetic patients, appears to be unsettled. Although chromiumsupplementation may be prescribed for individuals who are chromiumdeficient, the prevalence of chromium deficiency in diabetic patientsappears to be difficult to establish.

Without limiting the invention to a particular mechanism of action,chromium at the appropriate dosage and form may cause improved glucoseor lipid metabolism by overcoming insulin resistance. Chromium mayincrease insulin binding to cells by increasing the number of insulinreceptors. Alternatively, chromium may increase insulin sensitivity byincreasing insulin receptor phosphorylation.

The present invention contemplates metal complex of chromium in whichthe chromium is bioavailable. Some examples of such sources of chromiuminclude chromium trichloride, chromium acetate, chromium nicotinate (orpolynicotinate), chromium picolinate, chromium glycinate, chromiumoxalate, chromium perchlorate, chromium salicylate, chromium nicotinateglycinate, chromium 4-oxo-pyridine-2,6-dicarboxylate, chromiumchelidamate or arginate; and chromium tris-acetylacetonate. Anotherpossible source of chromium is glucose tolerance factor, which containschromium thought to be complexed as chromium nicotinate. Finally, inaddition to those metal complexes specifically set forth herein, othersalts and complexes of chromium known to those of skill in the art arecontemplated by the present invention. As discussed generally above, the

complexes contemplated by the present invention may differ inbioavailability and potency.

The chromium complexes may contain chromium in the (III) (i.e.,trivalent), (VI) (i.e., hexavalent), or other valent states, although itis believed that the trivalent state is responsible for biologicaleffects of interest in the present invention and is therefore preferred.Chromium in many of the chromium containing complexes contemplated bythe present invention typically have chromium in the (III) valency.

Certain embodiments of the present invention contemplate doses ofchromium from about 100 mcg to about 5000 mcg or higher. Unlessexpressly provided otherwise, the dose amounts referred to herein referto the amount of chromium in any particular form, such as complex or inany particular valency. By way of example, to provide 200 mcg ofchromium using chromium trichloride, a patient would need to ingestabout 610 mcg of chromium trichloride.

Particular dosages of chromium contemplated by the present inventioninclude about 200 mcg, 300 mcg, 333 mcg, 500 mcg, 650 mcg, 750 mcg, 1000mcg, 1250 mcg, 1500 mcg, 2000 mcg, 2500 mcg, 3000 mcg, 3500 mcg, 4500mcg, and 5000 mcg, as well as other possible dosages determined by oneof skill in the art. Higher dosages, while they may be daily dosages,may be used as short term regimes (e.g. less than about one month) andmay taper into dosages in the lower end of the taught ranges. In certaininstances, it may be advantageous not to fall below about 250 to 600 mcgof chromium per day when tapering the dose.

In certain embodiments, the dose of chromium may be modified if thesupplement or composition contains a bioavailable source of vanadium.For example, the dose of chromium may be reduced by from about 10% toabout 75%, or alternatively 25%, 33%, 55%, or 66%. The amount ofreduction in the chromium dose may depend, in part, on the dose ofvanadium provided for in any supplement of the present invention, aswell as the source of the vanadium and the means of administration.

For any of the components described herein, the dose may be varied asnecessary, for example, to treat one or more specific conditions setforth herein, or for example, to reflect any differences inadministration or the nature of the components employed in anyparticular composition, method or program of the present invention. Forexample, the dose of chromium may be reduced as ingestion of thesupplement results in improved blood glucose controls. The patient mayneed to monitor a number of indices, such as blood glucose levels orHbA1c levels, to determine the appropriate dosing.

In additional embodiments of present invention, the dose of chromium isbased on the weight of the intended recipient. Accordingly, in oneembodiment of the present invention, the dose of chromium is in therange of about 0.001 mg or less/kg of body weight up to about 0.06 mg ormore/kg of body weight. In another embodiment of the present invention,the dose is at least about 0.01 mg/kg body weight. In still anotherembodiment of the present invention, the dose is in the range of about0.002 mg/kg of body weight up to about 0.02 mg/kg of body weight.

In further embodiments of the present invention, the dose of chromiummay be determined based on the intended recipient's condition. Forexample, in one embodiment, the dose of chromium may depend on thesubject's HbA1c level. Accordingly, in this particular example, for apatient having an HbA1c level in the range of about 7 up to about 8, adose of chromium is in the range of about 0.003 mg or less/kg of bodyweight up to about 0.009 mg or less/kg, for a patient having an HbA1clevel in the range of about 8 up to about 9, a dose of chromium is inthe range of about 0.005 mg/kg of body weight up to about 0.01 mg/kg ofbody weight, for a patient having an HbA1c level in the range of about10 up to about 11, a dose of chromium is in the range of about 0.006mg/kg of body weight up to about 0.015 mg/kg of body weight, and for apatient having an HbA1c level in the range of at least about 11, a doseof chromium in the range of about 0.007 mg/kg of body weight up to about0.04 mg or more/kg of body weight. Dosing for a particular's subjectcondition may be based on any of the parameters known in the art ordescribed herein useful for assessing the condition of any subject. Forexample, a number of parameters of blood serum, in addition to HbA1clevels, may be used to determine appropriate dosing. Other measurementsof import of potential use for dosing purposes are described herein.

Chromium in the trivalent state is one of the least toxic nutrients: thereference dose established by the US EPA is 350 times the upper limit ofthe Estimated Safe and Adequate Daily Dietary Intake (ESADDI) of 200 mcgper day, wherein the reference dose is defined as the estimate (withuncertainty spanning perhaps an order of magnitude) of a daily exposureto a human population, including sensitive subgroups, that is likely tobe without appreciable risk of deleterious effects over a lifetime.Consequently, the present invention contemplates doses of trivalentchromium that substantially surpass the ESADDI but which may benecessary to produce the greatest therapeutic effect.

3.2.2 Vanandium

In some embodiments, vanadium compounds of the present invention arebelieved to have an insulin mimetic effect. Vanadium, often in the formof vanadate appears in certain tissues to stimulate glucose transport,activate glycogen synthase, increase glycogen syntheses in fat cells,and stimulate carbohydrate uptake in the liver like insulin.

A commonly used source of vanadate is vanadyl sulfate. Upon ingestion,vanadyl sulfate is typically reduced to vanadate, which is a salt, ofvanadic acid. Glycogen synthase is an enzyme that causes the conversionof glucose into glycogen. Vanadate appears to activate glycogen synthasein the same manner as insulin. For example, vanadate appears to have noeffect if insulin concentration is at a maximum, whereas if insulin isat less than maximum, vanadate increases both glycogen synthaseactivation state and 2-deoxyglucose transport to the level obtained ifinsulin were at maximized. Vanadate and insulin activate glycogensynthase within similar time frames, and adrenaline partially reversesboth vanadate and insulin activated glycogen synthase. Also, insulin andvanadate counteract the activating effect of adrenaline on glycogenphosphorylase.

Dosages of vanadium in compositions of the present invention range fromless than 5 mg to more than 100 mg. Unless expressly provided otherwise,the dose amounts referred to herein refer to the amount of vanadium inany particular form, such as any particular complex or in any particularvalency.

Particular dosages of vanadium contemplated by the present inventioninclude about 0.1 mg, 1 mg, 5 mg, 10 mg, 20 mg, 25 mg, 50 mg, 75 mg, 100mg, and 125 mg. In certain embodiments, the amount of vanadiumadministered is about 5 mg to 50 mg. Typically, these are daily dosages.Higher dosages, while they may be daily dosages, may be used as shortterm regimes (e.g. less than about one month) and may taper into dosagesin the lower end of the taught ranges.

In certain embodiments, it may be useful to represent the precedingdoses may be in terms of vanadyl (VO²⁺) instead of vanadium. Suchdosages would be: 0.1 mg V, 0.13 mg VO²⁺; 1 mg V, 1.3 mg VO²⁺; 5 mg V,6.55 mg VO²⁺; 10 mg V, 13.1 mg VO²⁺; 20 mg V, 26.2 mg VO²⁺; 25 mg V,32.8 mg VO²⁺; 50 mg V; 65.5 mg VO²⁺; 75 mg V, 98.3 mg VO²⁺; 100 mg V,131 mg VO²⁺; and 125 mg V, 164 mg VO²⁺.

In certain embodiments, the compositions of the present inventioninclude vanadyl sulfate hydrate as a vanadium source. In one suchembodiment, the amount of elemental vanadium in the source of vanadiumsulfate hydrate was determined by elemental analysis to be approximately20% by weight, which corresponds to about five to six waters ofhydration per molecule of vanadyl sulfate. For any embodiment using sucha source of vanadyl sulfate hydrate, some of the common doses ofvanadium and the resulting amount of vanadyl sulfate hydrate necessaryto provide that amount of vanadium would be: 0.1 mg of vanadium, 0.5 mgof vanadyl sulfate hydrate; 20 mg of vanadium, 100 mg of vanadyl sulfatehydrate; 100 mg of vanadium, 500 mg of vanadyl sulfate hydrate.

In certain embodiments, the dose of vanadium may be modified if thesupplement or composition contains a bioavailable source of chromium.For example, the dose of vanadium may be reduced by from about 10% toabout 75%, or alternatively 25%, 33%, 55%, or 66%. The amount ofreduction in the vanadium dose may depend, in part, on the dose ofchromium provided for in any supplement of the present invention, aswell as the source of the chromium and the means of administration.

For any of the components described herein, the dose may be varied asnecessary, for example, to treat one or more specific conditions setforth herein, or for example, to reflect any differences inadministration or the nature of the components employed in anyparticular composition, method or program of the present invention. Forexample, the dose of vanadium may be reduced as ingestion of thesupplement results in improved blood glucose control. The patient mayneed to monitor a number of indices, such as blood glucose levels orHbA1c levels, to determine the appropriate dosing.

In additional embodiments of present invention, the dose of vanadium isbased on the weight of the intended recipient. Accordingly, in oneembodiment of the present invention, the dose of vanadium is in therange of about 0.1 mg or less/kg of body weight up to about 10 mg ormore/kg of body weight. In another embodiment of the present invention,the dose is at least about 0.3 mg/kg body weight. In still anotherembodiment of the present invention, the dose is in the range of about0.2 mg/kg of body weight up to about 0.8 mg/kg of body weight.

Alternatively, dosages based on the subject's weight may be based on theamount of vanadyl required in any embodiment of the present invention.Accordingly, in one embodiment of the present invention, the dose ofvanadyl is in the range of about 0.13 mg or less/kg of body weight up toabout 13 mg or more kg of body weight. In another embodiment of thepresent invention, the dose is at least about 0.42 mg/kg body weight. Instill another embodiment of the present invention, the dose is in therange of about 0.26 mg/kg of body weight up to about 0.10 mg/kg of bodyweight.

In further embodiments of the present invention, the dose of vanadiummay be determined based on the intended recipient's condition. Forexample, in one embodiment, the dose of vanadium may depend on thesubject's HbA1c level. Accordingly, in this particular example, for apatient having an HbA1c level in the range of about 7 up to about 8, adose of vanadium is in the range of about 0.05 mg or less/kg of bodyweight up to about 0.45 mg/kg; for a patient having an HbA1c level inthe range of about 8 up to about 9, a dose of vanadium is in the rangeof about 0.15 mg/kg of body weight up to about 0.6 mg/kg of body weight,for a patient having an HbA1c level in the range of about 10 up to about11, a dose of vanadium is in the range of about 0.3 mg/kg of body weightup to about 1.0 mg/kg of body weight, and for a patient having an HbA1clevel in the range of at least about 11, a dose of vanadium in the rangeof about 0.35 mg/kg of body weight up to about 2.0 mg or more/kg of bodyweight. Dosing for a particular's subject condition may be based on anyof the parameters known in the art or described herein useful forassessing the condition of any subject. For example, a number ofparameters of blood serum, in addition to HbA1c levels, may be used todetermine appropriate dosing. Other measurements of import of potentialuse for dosing purposes are described herein.

A number of vanadium containing compounds may be used in the presentinvention. For instance, vanadyl sulfate does not appear not to beassociated with any apparent toxicity during treatment periods of up toone year. In addition, it appears that vanadyl sulfate may be less toxicthan vanadate forms of vanadium. Other vanadium compounds contemplatedby the present invention include any of the following: vanadiumpentoxide; vanadium trisulfate; vanadyl chloride; vanadyl glycinate;vanadyl gluconate; vanadyl citrate; vanadyl lactate; vanadyl tartrate;vanadyl gluconate; vanadyl phosphate; sodium orthovanadate; vanadiumchelidamate or arginate; and vanadyl complexes with monoprotic bidentate2,4-diones. In addition to those vanadium complexes specifically setforth above, other organic, inorganic, salts and complexes of vanadium,including vanadyl complexes, known to those of skill in the art arecontemplated by the present invention.

The different vanadium-containing metal complexes of the presentinvention may contain vanadium in any number of vanadium valencies.Vanadyl ion is VO²⁺, which has vanadium in plus four oxidation state, isone form of vanadium that is preferred in supplements of the presentinvention.

3.2.3 Magnesium

Magnesium influences a broad diversity of functions in physiology andpathology. Magnesium is the second most abundant intracellular cation(positively charged element) in the body, predominately in muscle(skeletal and cardiac) and bone. It is required for over 300 enzymaticreactions.

For instance, magnesium is essential for maintaining the activity of thesodium potassium adenine triphosphate (Na—K-ATPase) pump. Magnesiumdeficiency results in depletion of intracellular potassium (the mostabundant intracellular cation) and sodium accumulation. In cardiacmuscle, this electrolyte abnormality may cause electrocardiographicchanges and cardiac irritability, leading to myocardial infarction andpotentially lethal arrhythmias.

The recommended daily allowance of magnesium for humans is 350 mg.Magnesium in mammals typically resides in three compartments: (1) bone;(2) intracellular bound form or an intracellular unbound form; and (3)in circulating bound and unbound forms. When the concentration ofcirculating magnesium in the bloodstream increases as a result of thedietary intake of magnesium, the magnesium is sequestered into one ofthe bound or intracellular forms. Hypomagensium is generally defined asa serum magnesium level concentration of less than 1.5 mEq/l.

The incidence of magnesium deficiency in Type 1 and Type 2 diabetesappears to be unclear. The diabetic patient may be at risk fordeveloping magnesium depletion via inadequate dietary intake andgastrointestinal and renal losses, especially with poorly controlledblood glucose and resultant glucosuria. However, the diagnosingmagnesium deficiency in the clinical setting remains extremely difficultbecause serum magnesium measures only 0.3% of the total body magnesiumand is therefore difficult to determine.

Magnesium, as used in the present invention, appears to improve glucosemetabolism and to arrest or reduce any diabetes associated risk factors.Many preparations of magnesium are available but they may differ inpotency, bioavailability (absorption), tolerability, and cost. Magnesiumtaken orally is absorbed primarily in the jejunum and ileum. Somemagnesium salts, such as the oxide or the

although inexpensive, are not highly soluble in water, poorly absorbedand associated with gastrointestinal side effects, especially diarrhea.Other magnesium-containing complexes present better solubility,bioavailability, potency, tolerability, safety, and predictability inrepleting intracellular and serum levels of magnesium.

Adjusting the dose as necessary for the particular magnesium complexemployed, a number of magnesium containing complexes, or mixturesthereof, may be used in the subject preparations. Such moleculesinclude: magnesium chloride; magnesium citrate; magnesium fumarate;magnesium succinate; magnesium orotate; magnesium aminodicarbonic acidfluoride, bromide and iodide; magnesium aspartate; magnesium stearate;magnesium glutamate; magnesium oxide; magnesium hydroxide; magnesiumcarbonate; magnesium hydrogen phosphate; magnesium glycerophosphate;magnesium trisilicate; magnesium hydroxide carbonate; magnesium acetate;magnesium citrate; magnesium gluconate; magnesium lactate; magnesiumascorbate; magnesium taurate; magnesium malate; and magnesiumdiglycinate.

It has been suggested that certain forms of magnesium are capable ofincreasing intracellular magnesium concentrations, whereas othermagnesium supplements merely increase extra-cellular magnesium levels,which may result in less of a therapeutic effect or none at all. Twomagnesium complexes that have been proposed to increase intracellularconcentrations are magnesium orotate and magnesium aspartate.

Like many metal-containing complexes, the different magnesium compoundshave different mechanisms of uptake in vivo. Additionally, uponadministration, including ingestion, the transition metal complexes mayundergo any number of reactions in vivo that affect the bioavailabilityand resulting therapeutic effect. By way of example, magnesium citrateis soluble in gastric fluid and thus is readily available for passiveabsorption in the upper gastrointestinal tract. Magnesium and taurinemay act to improve insulin sensitivity and to reduce vasoconstrictionand atherogenesis, and stabilize platelets. Magnesium acetate, magnesiumascorbate and magnesium lactate are soluble in gastric fluid and sharethe upper gastrointestinal passive absorption potential of magnesiumcitrate. The ascorbate radical serves as a source of vitamin C byconversion to ascorbic acid upon exposure to hydrochloric acid in thegastric fluid, whereas the magnesium ion is converted to solublemagnesium chloride. The satisfactory water solubility of magnesiumacetate, magnesium ascorbate, magnesium citrate and magnesium lactateprovide for a diffusional gradient of magnesium in the upper smallintestine where some passive absorption of magnesium occurs. Magnesiumoxide is converted to magnesium chloride in the stomach, and offers theadvantage of a high ionic magnesium content, since 60% by weight of themagnesium oxide molecule is elemental magnesium. Magnesium diglycinaterepresents a form of magnesium that is absorbed in part as an intactdipeptide in the proximal small intestine via a dipeptide transportpathway and therefore provides a third absorptive mechanism formagnesium. Magnesium stearate is useful as a lubricant when compressingthe composition into tablets. The observations for these magnesiumcomplexes is illustrative of the type of processes and chemicalreactions that may occur for any of the transitional metal complexesdescribed herein, including the chromium- and vanadium-containingcomplexes.

A variety of dosages, in amount of magnesium, are contemplated by thepresent invention. Unless expressly provided otherwise, the dose amountsreferred to herein refer to the amount of magnesium in any particularform, such as any particular complex. The dose may range from about 5 mgor less to 1000 mg or more. Specific dosages include about 5 mg, 10 mg,20 mg, 40 mg, 50 mg, 80 mg, 100 mg, 150 mg, 250 mg, 500 mg, 750 mg, 1000mg, 1500 mg, and 2000 mg. A preferred dose is 46 mg of magnesium.Typically, these are daily dosages. Higher dosages, while the may bedaily dosages, may be used as short term regimes (e.g. less than aboutone month) and may tamper into dosages in the lower end of the ranges.In many such instances it will be advantageous to not to fall belowabout 40 to 100 mg per day of magnesium when tampering the dose. As forthe chromium and vanadium components, the appropriate dose of magnesiummay be based on the weight of the intended recipient. Alternatively, asdiscussed for other components, the appropriate dose of magnesium may bebased on the condition of any subject, as assessed by a number ofvariables of import. Alternatively, the dosages may depend on the modeof administration. Alternatively, magnesium does may vary with theidentity and amounts of the other components in any supplement of thepresent invention. As for the other components of the subjectcompositions, appropriate dosages may depend on numerous factors, andmay be readily determined by one of skill in the art.

3.2.4 Aspirin (Acetyl Salicylic Acid) and Other Anti-platelet Agents

Aspirin (e.g. acetyl salicylic acid) may be use to reduce the risk ofeither primary (high risk for cardiovascular disease) or secondary(cardiovascular disease). The health promoting benefits of aspirinderive in part from its antiplatelet

. It appears to work, in part, by inhibiting cyclooxygenase, an enzymenecessary for the synthesis of thromboxane, a potent stimulator ofplatelet aggregation, a condition known to be increased in diabetes andto be causative in the atherosclerotic process. In patients withdiabetes and other glucose metabolism disorders, aspirin appears tocorrect this abnormal increase in platelet activity.

Platelet aggregation is implicated in thrombus formation, which involvesinteraction of aggregated platelets and activated coagulation factorswith a damaged vascular wall. Platelets are normally non-adherent, butupon damage to the endothelial lining of a vessel, the platelets adhereto exposed subendothelial collagen. The von Willebrand factor (vWF) isinvolved in this adhesion. Collagen and thrombin initiate plateletactivation and activate phospholipase C, which hydrolyzes membranephospholipids. Protein kinase C is thereby activated, and the calciumconcentration of platelet cytosol increases. Arachidonic acid isliberated from membrane phospholipids and is oxidized in part toprostaglandin H₂ (PGH₂) and TxA₂. After platelet aggregation, fibrinogenis converted to fibrin to secure the hemostatic platelet plug. Plateletaggregation is mediated by the PGH₂ derivative prostacyclin, which isalso a vasodilator. In the arachidonic acid cascade, aspirin acts as acyclooxygenase inhibitor, blocking the conversion of arachidonic acid tothe PGH₂ precursor prostaglandin G₂ (PGG₂). Because PGG₂ is a precursorto both TxA₂ and prostacyclin, aspirin blocks both the aggregationinducing and aggregation inhibiting effects of these factors.

Like aspirin, naproxen, indomethacin, piroxicam and acetaminopheninhibit production of the pain-producing prostaglandins by cox-2, butthey all, other than aspirin, substantially inhibit cox-1, whichproduces prostacyclin. Aspirin inhibits prostacyclin production theleast (3-4 hrs), and piroxicam the most (3-4 days). It is believed thatthat one aspirin taken every 3 days maximizes prostacyclin productionand minimizes production of TxA₂, which causes hypertension and has beenimplicated in development of vascular disease. Other non-cylooxygenaseinhibitors may be used for pain relief in addition to aspirin (e.g.,Tramadol-Ultram), or inhibitors of cox-2 only (e.g., Meloxicam, andSulindac (Clinoril)).

Because aspirin in doses above 80 mg per day may interfere with thesynthesis of prostaglandins necessary to protect the gastric mucosa,gastrointestinal hemorrhage may result if aspirin is used above such adose. Therefore, aspirin trials have used progressively smaller doses toavoid the risk of hemorrhage, and have found comparable suppression ofthromboxane with doses as low as 10 mg per day and with equal or greaterrisk reduction for cardiovascular end point.

In certain embodiments, the present invention may use standardizedwillow bark as the source of aspirin. Standardized willow bark is aChinese herb and is highly standardized source of aspirin.Alternatively, other, naturally occurring sources of acetyl salicylicacid may be used in the present invention. Typical dosage ranges ofacetyl salicylic acid include less than 10 mg to 100 mg or more.Particular doses of aspirin include about 5 mg, 10 mg, 20 mg, 40 mg, 50mg, 60 mg, 80 mg, 100 mg, 150 mg, 200 mg. Typically, these are dailydosages. Generally, although higher dosages are contemplated by theinvention, they are less preferred because of potential gastricdisturbances. In certain embodiments, it will be advantageous not tofall below about 40 to 80 mg per day when tolerable by a patient. As forthe other components of the subject compositions, the appropriate doseof aspirin may depend on the mode of administration. As for the othercomponents of the subject compositions, appropriate dosages may dependon numerous factors, and may be readily determined by one of skill inthe art. Such factors include the weight of the intended recipient orthe condition of the recipient.

3.2.5 Folic Acid

It is now well recognized that elevated blood homocysteine (asulfhydryl-containing amino acid) levels are a cardiovascular riskfactor. Homocysteine may injure arterial endothelial cells, may affectplatelet-endothelial cell interaction, and may be thrombogenic. Sucheffects appear to accelerate the artherogenic process in diabeticpatients. High homocysteine levels may be normalized by folic acidtreatment, which thereby may reduce arthersclerotic events.

As with other the compounds of the present invention, the presentinvention may be practiced in the absence of folic acid, although incertain embodiments, the present invention will contain about 400 toabout 600 mcg folic acid, or alternatively, about 400 mcg. Otherpossible doses include about 200 mcg or less, 300 mcg, 500 mcg, 600 mcg,and about 1000 mcg or more.

3.2.6 Vitamin E and Other Anti-oxidants

There is evidence that diabetes produces oxidative stress that may berelated to the many of the complications that accompany diabetes,including cardiovascular problems. Therefore, any compounds useful inreducing such stress may be valuable in the supplements of the presentinvention. Some possible candidates include the following:

a. Vitamin E

Vitamin E (free 2R, 4′R, 8′R-alpha-tocopherol) is the most widelystudied of the antioxidant vitamins. The interest in vitamin E as anantioxidant is based on the many demonstrations in humans that givingvitamin E as a supplement decreases the oxidation of low densitylipoprotein (LDL) ex vivo, an event critical in the atherogenic process.

It is believed that Vitamin E supplementation reduces significantlyatherosclerosis in primates, including humans. This observation assumesgreater importance in those with diabetes, in view of the fact that asmany as 60% of newly diagnosed diabetic patients already have clinicallyobvious cardiovascular disease. A number of studies confirm suchobservation/A significantly lower risk of coronary artery disease wasobserved in a four year, prospective, observational study in healthymiddle-aged men who had higher intakes of dietary vitamin E as comparedto those consuming small amounts. In another prospective,epidemiological study, middle-aged women free of cardiovascular diseaseat baseline were found to have a highly significant reduced risk ofcoronary artery disease if they had been on vitamin E supplements for atleast two years during the eight year study. In a more recent andsimilar seven year prospective study of postmenopausal women withoutcardiovascular disease, dietary vitamin E consumption, but not vitamin Aor C, was inversely associated with the risk of death from coronaryartery disease.

The Cambridge Heart Antioxidant Study (“CHAOS”) investigated vitamin Esupplementation in patients with coronary artery disease. CHAOS was anearly three year prospective, secondary interventional trial of 2002men and women, 10% of whom had diabetes, using vitamin E (free 2R, 4′R,8′R-alpha-tocopherol), 400 or 800 I.U. daily, in a randomized,placebo-controlled, double-blinded design. Either dose of vitamin E wasassociated with a dramatic and significant reduction of non-fatalmyocardial infarction. The benefit of treatment with vitamin E wasapparent after two hundred days, and the patients with diabetes alsoenjoyed the marked reduction in the risk of non-fatal heart disease.

Another benefit of vitamin E supplementation is believed to be thefavorable effect it has on insulin sensitivity, glucose metabolism, andlipid levels in both healthy subjects and patients with Type 2 diabetes.Conversely, in a prospective study of almost one thousand non diabetic,middle-aged men, low concentration of plasma vitamin E at baseline wasfound to be an independent and powerful predictor for the development ofType 2 diabetes during the four year study. A low level of vitamin E wasassociated with a greater than five-fold risk of developing diabetes inthe ensuing four years. In addition, vitamin E may restore reducedprostacyclin synthesis, thereby possibly treating neuropathy.

Vitamin E was well tolerated in the studies where it was given as asupplement, and in the CHAOS study, there was no difference between thealpha-tocopherol treatment (400 or 800 I.U.) or placebo groups for sideeffects. Because of the unusually high incidence of clinical heartdisease in newly diagnosed diabetic patients, and the favorable effectvitamin E has on the metabolic abnormalities of Type 2 diabetes, thepresent invention may contain vitamin E. Dosages may range up to 1200I.U. or more, especially 400-800 I.U., and particularly 400 I.U.

In addition to using alpha-tocopherol and its analogs and estersthereof, e.g., alpha-tocopherol acid succinate and alpha-tocopherolacetate, other equivalents of tocopherols may be used in the subjectpreparations, such as tocotrienols and their esters, and tocopherylnicotinate. Gamma tocopherol are believed to trap mutagenicelectrophiles such as NOx. Alpha-tocopherol acid succinate may be usefulfor preparing supplements in tablet form.

b. Alpha-lipoic Acid

Alpha-lipoic acid is a antioxidant and is an essential a coenzyme in theutilization of sugar (glucose) for energy production. Alpha-lipoic acidalso assists the body recycle and renew other antioxidants, e.g.vitamins C and E, Co-Q1O and glutathione, and neutralizes both oxygenand nitrogen free radicals, which are believed to play major causalroles in cardiovascular diseases. It has been suggested thatalpha-lipoic acid may increase intracellular glutathione levels. Morerecently, administration of alpha-lipoic acid to diabetic patients withneuropathy appeared to reduce significantly associated symptoms. Inaddition, DL-lipoic acid has been recommended for treatment of ametabolic aberration of pyruvate

, which is symptomatic of diabetes. Also, alpha-lipoic acid has beenused to treat circulatory problems resulting from diabetes.

In certain embodiments, the present invention will contain about 10 mgor less to about 600 mg or more alpha-lipoic acid, with the mostpreferred dose of 50 mg. Other possible dosages include 10 mg or less,25 mg, 75 mg, 100 mg, 150 mg, 200 mg, 250 mg, 300 mg, 400 mg, 500 mg,600 mg, and 750 mg or more. If a patient presents with neuropathy, anincreased dose of alpha-lipoic acid may be appropriate.

c. N-acetylcysteine

N-acetylcysteine (NAC) is a precursor to glutathione peroxidase.Evidence suggests that NAC has an affect on several conditions relatedto diabetes. For example, dietary NAC appeared to inhibit thedevelopment of peripheral neuropathy in STZ-induced diabetic rats.Sagara et al., Diabetologia 39:263-69 (1996). Administration of NAC wasshown to reduce apolipoprotein A1 by over 20% in NIDDM patients.Gilligan et al., Biochem. Biophys. Acta 1254:187-92 (1995). Dosages mayvary up to 1500 mg or more, and include dosages of 250 mg, 500 mg, 1000mg, 1500 mg, and 2000 mg.

d. Selenium

Selenium may be present as atomic selenium, but may also be a seleniumcompound, organic or inorganic. Any selenium compound that is non-toxicat the levels administered, and capable of being formulated with theother compounds of the formulation may be used. Examples of inorganicsources of selenium may include sodium selenite, selenium chloride,selenium oxide, selenium sulfide, sodium selenide, sodium selenate,selenium bromide, selenium oxybromide, selenium fluoride, seleniumoxyfluoride, selenium oxychloride, selenium hexafluoride, seleniumtetrabromide, selenium tetrachloride and selenium tetrafluoride. Organicselenium is available, for example, as kelp bound selenium contained ina colloidal polymannuronate complex or as Selen-yeast which is yeastgrown on media rich in selenium and/or selenium salts. Other usefulorganic sources include, for example, seleno-amino acids,seleno-proteins, selenium-rich extracts of biological materials,selenols such as methyl selenol and ethyl selenol, and selenophenolssuch as selenophenol itself. Dose may range up to 200 mcg or more (basedon elemental selenium), and particular dosages include 40 mcg or less,60 mcg, 80 mcg, 100 mcg, 150 mcg, 200 mcg, and 250 mcg or more.

Another possible component for improving anti-oxidant capabilities isginko biloba extract. A possible dose is 120 mg, but the dose may vary.Finally, other well-known anti-oxidants that are contemplated by thepresent invention include both synthetic and naturally occurring ones:vitamin A (β-carotene and other carotenoids) vitamin C, selenium,probucol, drugs that inhibit superoxide anion formation or increase itsdestruction, and lipoxygenase inhibitors. In addition, diets rich inoleic acid may prove useful.

3.2.7 Vitamin A

The present invention contemplates formulations containing vitamin A,including retinoids, β-carotene, α-carotene, cryptoxanthine, and otherequivalents. Possible dosages of Vitamin A or its equivalents include upto 5000 I.U. or more.

These components may be combined in certain embodiments with othervitamin and mineral supplements. These additional ingredients may betaken simultaneously. Other vitamins and minerals are important in themetabolism of glucose and the maintenance of good health and may beingested from food or included in a supplement. Some of these othervitamins and minerals include calcium, copper, and zinc.

It should be recognized that the amounts of these vitamins and mineralsmay vary widely within the scope of the present invention.

3.3 Pharmacogenetics

In another aspect, embodiments of the present invention are directed todiagnostic and prognostic methods for determining whether a subject isat risk for developing diabetes, and in particular, Type 2 diabetes.Knowledge of a predisposition to developing impaired glucose metabolismallows for customization of a therapy or treatment regimen to anindividual's genetic profile, which is aim of pharmacogenomics. Thecomparison of an individual's profile to the population profile for thedisease permits the selection or design of supplements that are expectedto be safe and efficacious for a particular patient or patientpopulation (i.e., a group of patients having the same geneticalteration).

In particular, genetic screening would allow individuals that may besusceptible to diabetes to be identified readily, whereupon treatmentwith supplements of the present invention may be used to treat and/orprevent any disorders or conditions related to diabetes before onset ofclinical symptoms. In addition, administration of a supplement of thepresent invention, with respect to both the effective dose and thetiming of administration, may be optimized for different geneticpopulations.

Family studies point to a major genetic component in diabetes. Newman,et al., Diabetologia 30:763-68 (1987); Köbberling, Diabetologia 7:4649(1971); Cook, Diabetologia 37:1231-40 (1994). The disease is believed tobe polygenic in nature. Permutt et al., Recent Progress in HormoneResearch 53:201-16 (1998).

A number of genotypes have been associated with different forms ofdiabetes. Mutations in human HNF genes may result in Type 2 diabetes.U.S. Pat. Nos. 5,795,726; 5,800,998. For instance, genetic lesions thatmay cause or contribute to diabetes include alterations affecting theintegrity of a gene encoding an HNF1 and/or 4 protein, or themis-expression of the HNF1 and/or 4 gene. A large number of assaytechniques for detecting lesions in an HNF1 and/or 4 gene are describedin the two above-referenced patents. Many of these assay techniquesinvolve amplification of nucleic acids, often by polymerase chainreaction (PCR) or related techniques. Others use antibodies directedagainst wild type or mutant HNF1 and/or 4 proteins. The assay methodsdescribed therein may be performed, for example, by utilizingpre-packaged diagnostic kits comprising at least one probe nucleic acidor antibody reagent described therein, which may be conveniently used,e.g., in clinical settings to diagnose patients exhibiting symptoms orfamily history of a disease or illness involving an HNF1 and/or 4 gene.

In another report, genetic mutations in mitochondrial genes wereobserved to segregate with late onset diabetes. U.S. Pat. No. 5,840,493.Mutations in two genes, mitochondrial ATP synthase gene andmitochondrial tRNA lysine gene, were reported to correlate with thepresence or risk of Type 2 diabetes. In another report, anon-conservative missense mutation in the β-3-adrenergic receptor isassociated with susceptibility to, and development of Type 2 diabetesand obesity. U.S. Pat. No. 5,766,851. The responsible mutation is atcodon 64. The present invention contemplates screening for mutations orgenetic lesions in these genes to identify individuals that mightbenefit from administration of the subject supplements before the on-setof Type 2 diabetes and thereafter.

In addition, the genetic basis of a few rare monogenic syndromes of Type2 diabetes have been elucidated. Linkage to diabetes was observed torare early-onset forms of Type 2 diabetes that is associated withchronic hyperglycemia and monogenic inheritance (MODY

). Bell et al., Proc. Natl. Acad. Sci. USA 8:1484-88 (1991); Froguel etal., Nature 356:162-64 (1992); Hattersley et al. Lancet 339:1307-10(1992); Vaxillaire et al., Nature Genet. 9:418-23 (1995). The defects inthe glucokinase (GCK) gene on human chromosome 7 have been found to beresponsible for the relatively rare MODY2 phenotype. Froguel et al.,supra.

The genes responsible for MODY1 and MODY3 have not as yet beenidentified. However, linkage studies have shown that MODY1 is tightlylinked to the adenosine deaminase gene (ADA) on human chromosome 20q.Bell et al., supra; Cox et al., Diabetes 41:401-07 (1992); Bowden etal., Diabetes 41:88-92 (1992). In addition, the MODY1 locus has beenrefined to a 13 centimorgan interval (about 7 Mb) on chromosome 20 inbands q11.2-q13.1. Rothschild et al., Genomics 13:560-64 (1992). Linkagestudies have shown that the gene responsible for MODY3 is containedwithin a 7 centimorgan interval bracketed by D12586 and D125342 on humanchromosome 12q. Vaxillaire et al., Nature Genetics 9:418-23 (1995). TheMODY3 gene was not found to be implicated in late-onset Type 2 diabetes.Lesage et al., Diabetes 44:1243-47 (1995).

Another locus has been identified for a rare early-onset form withmitochondrial inheritance. Van den Ouwenland et al., Nature Genet.1:368-71 (1992). In addition, Harris et al. identified a locus of NIDDM1on chromosome 2 that appears to play a role in Mexican Americandiabetes. Harris et al., Nature Genet. 13:161-66 (1996). Further,Mahtani et al. report evidence of the existence of a gene on humanchromosome 12, NIDDM2, that causes Type 2 diabetes associated with lowinsulin secretion. Mahtani et al., Nature Genetics 14:90-94 (1996).Mahtani et al. suggest that NIDDM2 and MODY3 represent different allelesof the same gene with severe mutations causing MODY3 and mildermutations giving rise to later-onset Type 2 diabetes characterized bylow insulin secretion.

Other reports indicate that diabetes-causing genes may be specific toindividual ethnic groups. As a result, the present inventioncontemplates preparing kits containing the proper materials and suppliesfor the appropriate genetic testing of discrete subpopulations, alongwith, in certain embodiments, the treatment and prevention regimensdisclosed herein. For example, in the Oji-Cree people of NorthernOntario, who have the world's third highest prevalence of Type 2diabetes, diabetic adults have a high frequency of a mutation, G319S,which affects the structure of HNF-1α.

As additional

lesions that may cause or contribute to diabetes are reported ordiscovered, the present invention contemplates using them as diagnosticor prognostic indicators for susceptibility to diabetes, especially Type2 diabetes. The supplements of the present invention may be usedpreventively to ameliorate conditions in individuals displaying agenetic profile with an increased risk for diabetes.

In yet another means of screening for diabetes, the levels of expressionat the mRNA of human insulin receptors A and B (HIR-A and HIR-B,respectively), have been associated with Type 2 diabetes or a geneticpredisposition to Type 2 diabetes. U.S. Pat. No. 5,719,022. A ratio of1:1: in the two mRNA levels is indicative of Type 2 diabetes or asusceptibility to Type 2 diabetes.

3.4 Dosage and Assays of Supplements, or Components Thereof

The dosage of any anti-diabetic agent or supplement, or any componentthereof, of the present invention will vary depending on the symptoms,age and body weight of the patient, the nature and severity of thedisorder to be treated or prevented, the route of administration, andthe form of the supplement. Possible dosage ranges and particulardosages have been presented above in discussing different componentsthat may be present in any supplement or composition of the presentinvention. Any of the subject formulations or anti-diabetic agents maybe administered in a single dose or in divided doses. Dosages for manyof the anti-diabetic agents discussed herein are known in the art.Dosages for anti-diabetic agents or supplements, or components thereof,may be readily determined by techniques known to those of skill in theart or as taught herein.

An effective dose or amount, and any possible affects on the timing ofadministration of the formulation, may need to be identified for anyparticular anti-diabetic agent or supplement, or component thereof, ofthe present invention. This may be accomplished by routine experiment asdescribed herein, using one or more groups of animals (preferably atleast 5 animals per group), or in human trials if appropriate. Theeffectiveness of any supplement and method of treatment or preventionmay be assessed by administering the supplement and assessing the effectof the administration by measuring one or more indices associated withglucose metabolism, and comparing the post-treatment values of theseindices to the values of the same indices prior to treatment.

The precise time of administration and/or amount of any particularanti-diabetic agent or supplement that will yield the most effectivetreatment in a given patient will depend upon the

pharmacokinetics, and bioavailability

a particular compound, physiological condition of the patient (includingage, sex, disease type and stage, general physical condition,responsiveness to a given dosage and type of medication), route ofadministration, etc. The guidelines presented herein may be used tooptimize the treatment, e.g., determining the optimum time and/or amountof administration, which will require no more than routineexperimentation consisting of monitoring the subject and adjusting thedosage and/or timing.

While the subject is being treated, glucose metabolism may be monitoredby measuring one or more of the relevant indices at predetermined timesduring a 24-hour period. Treatment, including supplement, amounts, timesof administration and formulation, may be optimized according to theresults of such monitoring. The patient may be periodically reevaluatedto determine the extent of improvement by measuring the same parameters,the first such reevaluation typically occurring at the end of four weeksfrom the onset of therapy, and subsequent reevaluations occurring everyfour to eight weeks during therapy and then every three monthsthereafter. Therapy may continue for several months or even years, witha minimum of three months being a typical length of therapy for humans.

Adjustments to the amount(s) of agent(s), drug(s), or supplement(s)administered and possibly to the time of administration may be madebased on these reevaluations. For example, if after four weeks oftreatment one of the metabolic indices has not improved but at least oneother has, the dose of different components of the formulation might beincreased by, for example, one-third. For example, if blood glucoselevels have not decreased sufficiently after a period of treatment by aformulation of the present invention, then the dosages of chromium andvanadium-containing complexes may be increased, or alternatively othercomplexes may be used, whereas the dose of aspirin would not necessarilyneed to be adjusted.

Treatment may be initiated with smaller dosages which are less than theoptimum dose of the compound. Thereafter, the dosage may be increased bysmall increments until the optimum therapeutic effect is attained.

The combined use of several components in any supplement in conjunctionwith an anti-diabetic agent of the present invention may reduce therequired dosage for any individual component because the onset andduration of effect of the different components may be complimentary. Insuch combined therapy, the different components and/or anti-diabeticagent(s) may be delivered together or separately, and simultaneously orat different times within the day. Often, the different components oranti-diabetic agent(s) may be administered substantially simultaneously,or alternatively as a composition or formulation containing bothcomponents. For example, it is known that vitamin C may regenerate andspare vitamin E, so any formulation having both of these compounds mayprovide complimentary protection against oxidative stress.

For assaying different anti-diabetic agents, supplements, or componentsthereof, and different treatment regimens, a variety of indices may needto be measured. For example, in an oral glucose tolerance test, apatient's physiological response to a glucose load or challenge isevaluated. After ingesting the glucose, the patient's physiologicalresponse to the glucose challenge is evaluated. Generally, this isaccomplished by determining the patient's blood glucose levels (theconcentration of glucose in the patient's plasma, serum, or whole blood)at several predetermined points in time. Guyton, Textbook of MedicalPhysiology 855-67 (8^(th) ed. 1991). Another related method is thehyperinsulinemic-euglycemic clamp.

Blood glucose measurements may be made by any number of methods. Thetiming of any blood glucose test may be material, and the presentinvention contemplates determining the fasting blood glucose level andespecially the post-prandial blood glucose level. In general, thedesirable fasting glucose level (or pre-prandial) is 80 to 120 mg/dL,and a non-diabetic has a pre-prandial glucose level of less than 110mg/dl. The desirable post-prandial level (or bedtime glucose level) is100 to 140 mg/dL, and a non-diabetic has a bedtime glucose level of lessthan 120 mg/dl. Under the American Diabetes Clinical PracticeRecommendations, additional action is recommended if the fasting bloodglucose level is greater than 140 mg/dl or the post-prandial glucoselevel is greater than 160 mg/dl. For older patients, or those withrelated complications, different treatment goals may be appropriate.

Some measurement methods for glucose employ invasive techniques, whichrequire taking a blood sample from the subject. Many invasive glucosesensors are based on electrochemical methods such as theelectroenzymatic method. Three enzymes are often used: glucose oxidase,hexokinase and glucose dehydrogenase. For example, blood glucose isoxidized by glucose-oxidase to produce gluconic acid and hydrogenperoxide. Glucose concentrations may be determined by measuring oxygenconsumed or hydrogen peroxide produced (

method), or by measuring

acid produced (potentiometric method).

Alternatively, it may be possible to determine blood glucose levels byusing non-invasive methods. Non-invasive technologies that have beenused or proposed for measuring glucose levels in tissue include: near-IRtransmission and reflectance, Near-IR Kromoscopy, spatially resolveddiffuse reflectance, polarimetry measurements, raman measurements, andPA measurements. In another example, it is possible to monitor apatient's blood glucose levels and insulin levels by monitoring ECGchanges upon glucose uptake. This method does not work for Type 1diabetic patients, however, because they lack the necessary pancreaticinsulin response. In another method, blood glucose levels may bemeasured by irradiating blood vessels in the retina of the eye. Finally,other spectroscopic methods have been proposed and are known to those ofskill in the art.

Another clinical index for glucose metabolism is glycosylated hemoglobinA. Human adult hemoglobin (Hb) typically consists of HbA, HbA2, and HbF.These forms of hemoglobin differ by virtue of their primary structure(i.e., amino acid sequence). Normally, HbA constitutes about 97% of thetotal hemoglobin present, HbA2 constitutes about 2.5% of the total, andHbF, also known as fetal hemoglobin, only about 0.5%.

Chromatographic analysis of HbA has shown that it contains a number ofminor hemoglobin species. These minor species have been designatedHbA1a, HbA1b, and HbA1c. These species are referred to as glycosylatedhemoglobins or glycohemoglobins, and are formed by condensation of theamino group of the hemoglobin with a keto moiety of a sugar. For HbA1c,the sugar is glucose, and the glycosylated hemoglobin is formed by thecondensation of the N-terminal valine amino acid of each β-chain ofhemoglobin with glucose to form an unstable Schiffbase or aldimine (alsoknown as pre-A1c), which then undergoes an Amadori rearrangement to forma stable ketoamine. Methods have been developed to distinguish betweenthe stable and labile forms of HbA1c so as to provide more accuratemeasurements of the stable HbA1c.

The formation of glycosylated hemoglobins is non-enzymatic and occursover the lifespan of the red cell, which is about 120 days under normalconditions. The amount of HbA1c is proportional to the concentration ofglucose in the blood, and is therefore related to time-averaged glucoseconcentration over the period prior to the measurement, which isapproximately two to three months. HbA1c values may be used to assessdiabetic control, in which short-term fluctuations in plasma glucoselevels do not affect the measurement. In general, the desirable HbA1clevel is less than 7%, and less then 6% in a non-diabetic. Under theAmerican Diabetes Clinical Practice Recommendations, additional actionis recommended if a patient's HbA1c level exceeds 8%. VHA guidelinesrecommend measuring HbA1c levels at least once annually.

Measurement of glycosylated hemoglobins may augment other traditionalmethods of assessing control of glucose metabolism. For example,measurement of glycosylated hemoglobins may be used when urine glucoserecords are inadequate, when blood glucose levels vary markedlythroughout the day or from day to day, and for a new patient with knownor suspected diabetes in whom there is no previous record of bloodglucose concentration. A particular application for monitoringglycosylated hemoglobins is during pregnancy, when close control ofdiabetes is especially important.

There are a number of currently available methods for determining levelsof glycosylated hemoglobins, including ion exchange chromatography,high-performance liquid chromatography, affinity chromatography,colorimetry, radioimmunoassay, electrophoresis, and isoelectricfocusing. Ion exchange chromatography may be conducted using resinscontaining weakly acidic cation exchanges or negatively chargedcarboxymethylcellulose resin. High performance liquid chromatographyprovides a reliable reference method.

Affinity chromatography may be used to separate non-glycosylatedhemoglobin from glycosylated hemoglobin. A suitable affinity column isprepared having immobilized m-aminophenylboronic acid. The boronic acidreacts with the cis-diol groups of glucose bound to hemoglobin to form areversible 5-membered ring complex, thus selectively binding theglycosylated hemoglobin to the affinity column. Sorbitol disassociatesglycosylated hemoglobin from the column. For example, glycosylatedhemoglobin may be measured by a modification of the method of Clegg andSchroeder, Clegg et al., J. Lab Clin. Med. 102:577-89 (1983).

A calorimetric method has been devised based on the observation thatHbA1c, when subject to mild acid hydrolysis, releases5-hydroxymethylfurfural (5-HMF). Another spectrophotometric methodinvolves the reaction of inositol hexaphosphate (phytic acid) withhemoglobin. Absorbance increases at 633 nm and decreases at 560 nm. uponphytic acid binding to the N-terminal amino groups of the β-chains. Thischange only occurs for Hb A that is unglycosylated, so the change inabsorbance induced by phytic acid is thus inversely proportional to thefraction of glycosylated hemoglobin.

Antibody

against HbA1c may be prepared and

as the basis for a radioimmunoassay. Isoelectric focusing has also beenused as a method of quantitating HbA1c. In another method, capillaryelectrophoresis may be used, usually in conjunction with an antibodydirected against HbA1c.

Kits for measuring glycosylated hemoglobin are known in the art, andcontemplated by the present invention.

Fasting glucose levels may be measured by finger stick glucometerreadings. Samples of apolipoproteins may be analyzed on a proteinanalyzer using proper standardization techniques. Other indices may bemeasured by techniques known to those of skill in the art.

Animal-based studies may be conducted on different anti-diabetic agents,supplements, or components thereof, of the present invention asnecessary to determine combinations of the different components thatproduce the greatest therapeutic effect. For example, in rats thediabetic state may be induced by injecting streptozoticin (STZ) at anappropriate dose, for example 60 mg/kg dissolved in 0.9% NaCl IC via thetail vein upon anaesthetization. The diabetic state may be confirmed ata later time, whereupon assaying of different supplements may beginthereafter. Alternatively, insulin resistant spontaneously hypertensiverats (SHR) made be used, with the genetic control being the Wistar Kyoto(WKY) strain. Alternatively, the Zucker diabetic fatty rat (ZDF) a modelof spontaneous NIDDM, may be used, with the Zucker lean control (ZLC)rats as controls. In addition, transgenic mouse models may be useful inthe present invention.

Alternatively, the db/db mouse, a genetically obese and diabetic strainof mouse, may be used in animal studies. The db/db mouse developshyperglycemia and hyperinsulinemia concomitant with its development ofobesity and thus serves as a model of obese Type 2 diabetes. The db/dbmice may purchased from, for example, the Jackson Laboratories (BarHarbor, Me.). In an exemplary embodiment, for treatment of mice with aregimen including a formulation of the present invention or control,sub-orbital sinus blood samples may be taken before and at some timeafter dosing of each animal.

Toxicity and therapeutic efficacy of anti-diabetic agents, supplements,or components thereof, may be determined by standard pharmaceuticalprocedures in cell cultures or experimental animals, e.g., fordetermining the LD₅₀ (the dose lethal to 50% of the population) and theED₅₀ (the dose therapeutically effective in 50% of the population). Thedose ratio between toxic and therapeutic effects is the therapeuticindex and it may be expressed as the ratio

₅₀/ED₅₀. Compositions that exhibit

therapeutic indices are preferred. Although supplements that exhibittoxic side effects may be used, care should be taken to design adelivery system that targets the component(s) of any supplementresponsible for any toxic effects to the desired site in order to reduceside effects.

The data obtained from the cell culture assays and animal studies may beused in formulating a range of dosage for use in humans. The dosage ofany supplement, or alternatively of any components therein, liespreferably within a range of circulating concentrations that include theED₅₀ with little or no toxicity. The dosage may vary within this rangedepending upon the dosage form employed and the route of administrationutilized. For any supplement or components thereof of the presentinvention, the therapeutically effective dose may be estimated initiallyfrom cell culture assays. A dose may be formulated in animal models toachieve a circulating plasma concentration range that includes the IC₅₀(i.e., the concentration of the test compound which achieves ahalf-maximal inhibition of symptoms) as determined in cell culture. Suchinformation may be used to more accurately determine useful doses inhumans. Levels in plasma may be measured, for example, by highperformance liquid chromatography.

3.5 Formulations of Supplements, or Components Thereof

The anti-diabetic agents, compositions and supplements of the presentinvention may be administered in various forms, depending on thedisorder or condition to be treated and the age, condition and bodyweight of the patient, as is well known in the art. It will also beappreciated that each of the different components can be administeredindividually, or alternatively each can be formulated into onemedicament for administration to the patient. In preferred embodiments,each of the different components is formulated as a tablet, capsule, orother appropriate ingestible formulation as discussed in more detailbelow, to provide a therapeutic dose in ten tablets or fewer. Inparticularly preferred embodiments, a therapeutic dose is provided infive tablets or fewer. In most preferred embodiments, a therapeutic doseis provided in three tablets or fewer. For any of the modalitiespresented herein, different anti-diabetic agents or components of anysubject supplement may be administered by different methods as necessaryfor effective delivery of the component, or as otherwise necessary forconvenience. For example, where the formulation is to be administeredorally, it may be formulated as tablets, capsules, granules, powders orsyrups. Alternatively, formulations of the present invention may beadministered parenteral, as injections (intravenous, intramuscular orsubcutaneous), drop infusion preparations, or suppositories. Forapplication by the ophthalmic mucous membrane route, they may beformulated as eyedrops or eye ointments. These formulations may beprepared by conventional means, and, if desired, the active ingredientmay be mixed with any conventional additive, such as an excipient, abinder, a disintegrating agent, a lubricant, a corrigent, a solubilizingagent, a suspension aid, an emulsifying agent or a coating agent.

In formulations of the subject anti-diabetic agents, supplements andcompositions, wetting agents, emulsifiers and lubricants, such as sodiumlauryl sulfate and magnesium stearate, as well as coloring agents,release agents, coating agents, sweetening, flavoring and perfumingagents, preservatives and antioxidants may be present in thesupplements.

Formulations useful in the methods of the present invention includethose suitable for oral, nasal, topical (including buccal andsublingual), rectal, vaginal, aerosol and/or parenteral administration.The formulations may conveniently be presented in unit dosage form andmay be prepared by any methods well known in the art of pharmacy. Theamount of supplement or components thereof which may be combined with acarrier material to produce a single dosage form will vary dependingupon the subject being treated, and the particular mode ofadministration. The amount of active ingredient which may be combinedwith a carrier material to produce a single dosage form will generallybe that amount of the compound which produces a therapeutic effect.Generally, out of one hundred per cent, this amount may range from about1 per cent to about ninety-nine percent of active ingredient,particularly from about 5 per cent to about 70 per cent, especially fromabout 10 per cent to about 30 per cent.

Methods of preparing these formulations or compositions include the stepof bringing into association a supplement or components thereof with thecarrier and, optionally, one or more accessory ingredients. In general,the formulations are prepared by uniformly and intimately bringing intoassociation a supplement or components thereof with liquid carriers, orfinely divided solid carriers, or both, and then, if necessary, shapingthe product.

Formulations suitable for oral administration may be in the form ofcapsules, cachets, pills, tablets, lozenges (using a flavored basis,usually sucrose and acacia or tragacanth), powders, granules, or as asolution or a suspension in an aqueous or non-aqueous liquid, or as anoil-in-water or water-in-oil liquid emulsion, or as an elixir or syrup,or as pastilles (

an inert base, such as gelatin and

, or sucrose and acacia), each containing a predetermined amount of asupplement or components thereof as an active ingredient. A supplementor components thereof may also be administered as a bolus, electuary, orpaste.

In solid dosage forms for oral administration (capsules, tablets, pills,dragees, powders, granules and the like), the supplement or componentsthereof is mixed with one or more pharmaceutically-acceptable carriers,such as sodium citrate or dicalcium phosphate, and/or any of thefollowing: (1) fillers or extenders, such as starches, lactose, sucrose,glucose, mannitol, and/or silicic acid; (2) binders, such as, forexample, carboxymethylcellulose, alginates, gelatin, polyvinylpyrrolidone, sucrose and/or acacia; (3) humectants, such as glycerol;(4) disintegrating agents, such as agar-agar, calcium carbonate, potatoor tapioca starch, alginic acid, certain silicates, and sodiumcarbonate; (5) solution retarding agents, such as paraffin; (6)absorption accelerators, such as quaternary ammonium compounds; (7)wetting agents, such as, for example, acetyl alcohol and glycerolmonostearate; (8) absorbents, such as kaolin and bentonite clay; (9)lubricants, such a talc, calcium stearate, magnesium stearate, solidpolyethylene glycols, sodium lauryl sulfate, and mixtures thereof; and(10) coloring agents. In the case of capsules, tablets and pills, thepharmaceutical compositions may also comprise buffering agents. Solidcompositions of a similar type may also be employed as fillers in softand hard-filled gelatin capsules using such excipients as lactose ormilk sugars, as well as high molecular weight polyethylene glycols andthe like.

A tablet may be made by compression or molding, optionally with one ormore accessory ingredients. Compressed tablets may be prepared usingbinder (for example, gelatin or hydroxypropylmethyl cellulose),lubricant, inert diluent, preservative, disintegrant (for example,sodium starch glycolate or cross-linked sodium carboxymethyl cellulose),surface-active or dispersing agent. Molded tablets may be made bymolding in a suitable machine a mixture of the supplement or componentsthereof moistened with an inert liquid diluent. Tablets, and other soliddosage forms, such as dragees, capsules, pills and granules, mayoptionally be scored or prepared with coatings and shells, such asenteric coatings and other coatings well known in thepharmaceutical-formulating art.

Tablets and other solid dosage forms may also be formulated so as toprovide slow or controlled release of the active ingredient thereinusing, for example, hydroxypropylmethyl cellulose in varying proportionsto provide the desired release profile, other polymer

, liposomes and/or microspheres they may be sterilized by, for example,filtration through a bacteria-retaining filter, or by incorporatingsterilizing agents in the form of sterile solid compositions which maybe dissolved in sterile water, or some other sterile injectable mediumimmediately before use. These compositions may also optionally containopacifying agents and may be of a composition that they release theactive ingredient(s) only, or preferentially, in a certain portion ofthe gastrointestinal tract, optionally, in a delayed manner. Examples ofembedding compositions which may be used include polymeric substancesand waxes. The active ingredient may also be in micro-encapsulated form,if appropriate, with one or more of the above-described excipients.

Liquid dosage forms for oral administration include pharmaceuticallyacceptable emulsions, microemulsions, solutions, suspensions, syrups andelixirs. In addition to the supplement or component, the liquid dosageforms may contain inert diluents commonly used in the art, such as, forexample, water or other solvents, solubilizing agents and emulsifiers,such as ethyl alcohol, isopropyl alcohol, ethyl carbonate, ethylacetate, benzyl alcohol, benzyl benzoate, propylene glycol, 1,3-butyleneglycol, oils (in particular, cottonseed, groundnut, corn, germ, olive,castor and sesame oils), glycerol, tetrahydrofuryl alcohol, polyethyleneglycols and fatty acid esters of sorbitan, and mixtures thereof.

Besides inert diluents, the oral compositions may also include adjuvantssuch as wetting agents, emulsifying and suspending agents, sweetening,flavoring, coloring, perfuming and preservative agents.

Suspensions, in addition to the supplement or components thereof, maycontain suspending agents as, for example, ethoxylated isostearylalcohols, polyoxyethylene sorbitol and sorbitan esters, microcrystallinecellulose, aluminum metahydroxide, bentonite, agar-agar and tragacanth,and mixtures thereof.

Formulations for rectal or vaginal administration may be presented as asuppository, which may be prepared by mixing one or more component withone or more suitable non-irritating excipients or carriers comprising,for example, cocoa butter, polyethylene glycol, a suppository wax or asalicylate, and which is solid at room temperature, but liquid at bodytemperature and, therefore, will melt in the rectum or vaginal cavityand release the active agent.

Formulations which are suitable for vaginal administration also includepessaries, tampons, creams, gels, pastes, foams or spray formulationscontaining such carriers as are known in the art to be appropriate.

Dosage forms for transdermal administration of an anti-diabetic agent,supplement or component includes powders, sprays, ointments, pastes,creams, lotions, gels, solutions, patches and inhalants. The activecomponent may be mixed under sterile conditions with apharmaceutically-acceptable carrier, and with any preservatives,buffers, or propellants which may be required. For transdermaladministration of transition metal complexes, the complexes may includelipophilic and hydrophilic groups to achieve the desired watersolubility and transport properties.

The ointments, pastes, creams and gels may contain, in addition to asupplement or components thereof, excipients, such as animal andvegetable fats, oils, waxes, paraffins, starch, tragacanth, cellulosederivatives, polyethylene glycols, silicones, bentonites, silicic acid,talc and zinc oxide, or mixtures thereof.

Powders and sprays may contain, in addition to a supplement orcomponents thereof, excipients such as lactose, talc, silicic acid,aluminum hydroxide, calcium silicates and polyamide powder, or mixturesof these substances. Sprays may additionally contain customarypropellants, such as chlorofluorohydrocarbons and volatile unsubstitutedhydrocarbons, such as butane and propane.

Anti-diabetic agent(s) or components of the supplement may alternativelybe administered by aerosol. For example, insulin deliver by aerosol hasbeen proposed. U.S. Pat. No. 5,813,397. This is accomplished bypreparing an aqueous aerosol, liposomal preparation or solid particlescontaining the compound. A non-aqueous (e.g., fluorocarbon propellant)suspension could be used. Sonic nebulizers are preferred because theyminimize exposing the agent to shear, which may result in degradation ofthe compound.

Ordinarily, an aqueous aerosol is made by formulating an aqueoussolution or suspension of the agent together with conventionalpharmaceutically acceptable carriers and stabilizers. The carriers andstabilizers vary with the requirements of the particular compound, buttypically include non-ionic surfactants (Tweens, Pluronics, orpolyethylene glycol), innocuous proteins like serum albumin, sorbitanesters, oleic acid, lecithin, amino acids such as glycine, buffers,salts, sugars or sugar alcohols. Aerosols generally are prepared fromisotonic solutions.

Transdermal patches have the added advantage of providing controlleddelivery of a component of a supplement to the body. Such dosage formsmay be made by dissolving or dispersing the agent in the proper medium.Absorption enhancers may also be used to increase the flux of thecomponent across the skin. The rate of such flux may be controlled byeither providing a rate controlling membrane or dispersing the componentin a polymer matrix or gel.

Ophthalmic formulations, eye ointments, powders, solutions and the like,are also contemplated as being within the scope of this invention.

Pharmaceutical compositions of this invention suitable for parenteraladministration comprise one or more components of a supplement incombination with one or more pharmaceutically-acceptable sterileisotonic aqueous or non-aqueous solutions, dispersions, suspensions oremulsions, or sterile powders which may be reconstituted into sterileinjectable solutions or dispersions just prior to use, which may containantioxidants, buffers, bacteriostats, solutes which render theformulation isotonic with the blood of the intended recipient orsuspending or thickening agents.

Examples of suitable aqueous and non-aqueous carriers which may beemployed in the pharmaceutical compositions of the invention includewater, ethanol, polyols (such as glycerol, propylene glycol,polyethylene glycol, and the like), and suitable mixtures thereof,vegetable oils, such as olive oil, and injectable organic esters, suchas ethyl oleate. Proper fluidity may be maintained, for example, by theuse of coating materials, such as lecithin, by the maintenance of therequired particle size in the case of dispersions, and by the use ofsurfactants.

These formulations may also contain adjuvants such as preservatives,wetting agents, emulsifying agents and dispersing agents. Prevention ofthe action of microorganisms may be ensured by the inclusion of variousantibacterial and antifungal agents, for example, paraben,chlorobutanol, phenol sorbic acid, and the like. It may also bedesirable to include isotonic agents, such as sugars, sodium chloride,and the like into the compositions. In addition, prolonged absorption ofthe injectable pharmaceutical form may be brought about by the inclusionof agents which delay absorption such as aluminum monostearate andgelatin.

In some cases, in order to prolong the effect of an anti-diabetic agentor component of a supplement, it is desirable to slow the absorption ofthe drug from subcutaneous or intramuscular injection. This may beaccomplished by the use of a liquid suspension of crystalline or

material having poor water solubility. The rate of absorption of thedrug then depends upon its rate of dissolution which, in turn, maydepend upon crystal size and crystalline form. Alternatively, delayedabsorption of a parenterally-administered drug form is accomplished bydissolving or suspending the drug in an oil vehicle.

Injectable depot forms are made by forming microencapsule matrices ofcomponents of a supplement in biodegradable polymers such aspolylactide-polyglycolide. Depending on the ratio of component topolymer, and the nature of the particular polymer employed, the rate ofcomponent release may be controlled. Examples of other biodegradablepolymers include poly(orthoesters) and poly(anhydrides). Depotinjectable formulations are also prepared by entrapping the component inliposomes or microemulsions which are compatible with body tissue.

EXEMPLIFICATIONS

The present invention now being generally described may be more readilyunderstood by reference to the following examples which are includedmerely for purposes of illustration of certain aspects and embodimentsof the present invention, and are not intended to limit the invention.

Example One

A supplement (detailed below) was administered daily to a female withType 2 diabetes who was experiencing poor blood sugar control whiletaking metformin 500 mg b.i.d. In conjunction with continued metforminadministration, the patient was given an oral daily nutritionalsupplement comprising the following ingredients: chromium 333 mcg (inthe form of chromium picolinate/polynicotinate); magnesium 46 mg (in theform of 384 mg magnesium chloride); vanadyl-sulfate hydrate 100 mg;vitamin E 400 I.U, and folate 400 mcg.

The results are summarized below in Table I TABLE 1 HbAlc EstimatedBlood Fasting Blood Therapeutic Regimen Level Sugar (mg/dL) Sugar(mg/dL) Metformin alone 9.7 200 185 Metformin & 7.9 141 153 composition(after 2 months)

The above results indicate the degree to which a composition consistingof components and an anti-diabetic agent according to the presentinvention, administered in accordance with invention methods, maydramatically improve blood sugar control and reduce HbA1c levels whencompared to treatment with an anti-diabetic agent alone, such asmetformin.

In addition to the lowered HbA1c and fasting blood sugar levels, thepatient experienced a significant lowering of total cholesterol and aconcomitant lowering of triglyceride, HDL and LDL levels, as summarizedbelow in Table 2. TABLE 2 Therapeutic Cholesterol LDL HDL TriglyceridesMetformin alone 229 133 52 220 Metformin & 192 114 38 200 composition(after 2 months)

The results summarized in Table 2 indicate that a composition comprisingcomponents and an anti-diabetic agent according to the presentinvention, administered in accordance with invention methods, alsodramatically reduces overall cholesterol levels, improves the LDL:HDLratio and lowers serum triglyeceride levels when compared to treatmentwith metformin alone.

Example Two

To further test the efficacy of inventive compositions, a certainembodiment of the present invention, the supplement detailed below, wasadministered daily to a 27 year old female with Type 2 diabetes who wasexperiencing poor blood sugar control while taking metformin 1000 mgb.i.d.

After 3 months of augmenting the daily regimen of 2000 mg metformin withthe above oral nutritional supplement, the patient's HbA1c level droppedfrom 8.3 to 6.1. These results again serve to demonstrate the degree towhich invention compositions, administered in accordance with inventionmethods, serves to beneficially lower a diabetic patient's HbA1c levels,even though the patient had experienced poor blood glucose control onhigh doses of metformin alone.

Example Three

In another example, a group of Type 2 diabetic individuals presentingwith elevated HbA1c levels were placed on a program using a variety ofembodiments of the present invention. The study was conducted as anopen-label study at five different medical centers in the United States.The patients were on the program for three months, and were directed notto change their dietary habits or lifestyle, including exercisepatterns.

For this Example Three, one daily dose of every embodiment contained, inaddition to any of the anti-diabetic agents set forth in theaccompanying tables, the following (component and amount):

Vitamin A, 5000 IU; Vitamin C (Ascorbic Acid), 60 mg; Vitamin D-3, 400IU; Vitamin E (free 2R, 4′R, 8′R-alpha-tocopherol), 400 IU; Thiamine (asThiamine Mononitrate), 3 mg; Riboflavin, 3.6 mg; Niacinamide, 20.1 mg;Vitamin B-6 (as Pyridoxine HCl), 23.1 mg; Folic Acid, 400 mcg; VitaminB-12, 48 mcg; Biotin, 300 mcg; Pantothenic Acid (as CalciumPantothenate), 10 mg; Calcium (from Calcium Carbonate/Phosphate), 150mg; Phosphorous (from Calcium Phosphate), 115 mg; Iodine (from SeaKelp), 150 mg; Magnesium (elemental Magnesium from 307 mg MagnesiumComplex of citrate/fumuarte/malate/gluturate-/succinate/chloride), 46mg; Zinc, 15 mg; Selenium (from Selenium Krebs), 60 mcg; Manganese (fromManganese Sulfate), 11 mg; Chromium (from 3264 mcg ChromiumPicolinate/Polynicotinate Complex (50%/50%)), 333 mcg; Vanadyl Sulfatehydrate, 100 mg; Willow (bark) (standardized willow/willow bark complex)(aspirin 20 mg), 160 mg. In the examples described herein, chromiumpicolinate was obtained from Nutrition 21 or AMBI Inc., and chromiumpolynicotinate was obtained from InterHealth. The vanadium sulfatehydrate in this example was determined to contain about 20% elementalvanadium by weight, which corresponds to about five to six waters ofhydration for every molecule of vanadyl sulfate.

REFERENCES

All publications and patents mentioned herein, including those itemslisted below, are hereby incorporated by reference in their entirety asif each individual publication or patent was specifically andindividually indicated to be incorporated by reference. In case ofconflict, the present application, including any definitions herein,will control.

Patents and Patent Applications

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Those skilled in the art will recognize, or be able to ascertain usingno more than routine experimentation, many equivalents to the specificembodiments of the invention described herein. Such equivalents areintended to be encompassed by the following claims.

1-96. (canceled)
 97. A composition comprising synergistic effectiveamounts of an anti-diabetic agent other than insulin, a bioavailablesource of chromium, and a bioavailable source of vanadium, wherein saidanti-diabetic agent is metformin, and wherein components of saidcomposition synergistically reduce the HbA1c levels of a patient by atleast about 10% after treatment for a period of at least about thirtydays with said composition as compared to treatment with saidanti-diabetic agent alone.
 98. The composition of claim 97, wherein saidreduction in said Hb1Ac level is at least about 50%.
 99. The compositionof claim 97, wherein said bioavailable source of chromium comprises oneor more of chromium picolinate or chromium polynicotinate.
 100. Thecomposition according to claim 99, wherein the bioavailable source ofchromium is chromium picolinate and wherein the amount of chromiumpicolinate is from about 30 μg up to about 1000 μg, per dose.
 101. Thecomposition according to claim 99, wherein the bioavailable source ofchromium is chromium polynicotinate and wherein the amount of chromiumpolynicotinate is from about 30 μg up to about 5000 μg, per dose. 102.The composition of claim 97, wherein said bioavailable source ofchromium comprises no less than about 200 micrograms of elementalchromium.
 103. The composition of claim 97, wherein said bioavailablesource of chromium comprises no less than about 100 micrograms ofelemental chromium.
 104. The composition of claim 97, wherein saidbioavailable source of chromium comprises no less than about 5micrograms of elemental chromium.
 105. The composition of claim 97,wherein said bioavailable source of vanadium is vanadyl sulfate. 106.The composition of claim 105, wherein the amount of vanadyl sulfate isin the range of about 20 mg up to about 100 mg, per dose.
 107. Thecomposition of claim 97, wherein said bioavailable source of vanadiumcomprises more than about 10 mg elemental vanadium.
 108. The compositionof claim 97, wherein said amount of said bioavailable source of vanadiumcomprises no less than 5 mg of elemental vanadium.
 109. A method forimproving glucose metabolism, comprising treating a patient for at leastabout a thirty day period by administering a pharmaceutical compositioncomprising synergistic effective amounts of an anti-diabetic agent otherthan insulin, a bioavailable source of chromium, and a bioavailablesource of vanadium, wherein said anti-diabetic agent is metformin, andwherein said components of said composition synergistically reduce theHbA1c level of said patient by at least about 10% after such treatmentas compared to treatment with said anti-diabetic agent alone.
 110. Themethod of claim 109, wherein said bioavailable source of chromiumcomprises no less than about 200 micrograms elemental chromium when saidcomposition is administered on a daily basis.
 111. The method of claim109, wherein said bioavailable source of chromium comprises no less thanabout 5 micrograms of elemental chromium when said composition isadministered on a daily basis.
 112. The method of claim 109, whereinsaid bioavailable source of chromium comprises one or more of chromiumpicolinate or chromium polynicotinate.
 113. The method of claim 109,wherein said bioavailable source of vanadium comprises at least about 10mg elemental vanadium when said composition is administered on a dailybasis.
 114. The method of claim 109, wherein said bioavailable source ofvanadium is vanadyl sulfate.
 115. The method of claim 109, wherein saidamount of said bioavailable source of vanadium comprises no less than 5mg of elemental vanadium when said composition is administered on adaily basis.
 116. The method of claim 109, wherein said pharmaceuticalcomposition further comprises a physiologically acceptable carrier. 117.The method of claim 109, wherein said method further comprisesmonitoring said subject's HbA1c levels.
 118. The method of claim 109,wherein said reduction in said Hb1Ac level is at least about 50%.